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Date of Birth (MM/DD/YYYY)
Office Location
Palm Bay
Pineda
Merritt Island
I'm Seeking Treatment For:
Acute Headaches
Arthritis
Back Pain
Bulging Disc
Cancer Pain
Carpal Tunnel Syndrome
Degeneration Disc Disease or DDD
Diabetic Peripheral Neuropathy
Extruded Discs
Face Pain
Fibromyalgia
Foot Pain
Groin Pain
Headaches
Heel Spur
Herniated Disc
Hip Pain
Joint Pain
Knee Pain
Leg Pain
Low Back Pain
Migraines Headaches
Motor Vehicle Injuries or MVA
Neck Pain
Osteoarthritis
Osteoporosis
Pelvic Pain
Phantom Limb Pain
Plantar Fasciitis
Post Herpetic Neuralgia
Post Laminectomy Pain
Prolapsed Disc
Prolotherapy
Reflex Sympathetic Dystrophy
Rotator Cuff Tear
Ruptured Disc
Sacroiliac Joint Pain or SI Joint Pain
Sciatica
Scoliosis
Sequestered Disc
Shingles
Spinal Decompression
Spinal Stenosis
Spinal Traction
Tension Headaches
Testicular Pain
Thoracic Pain
Trigeminal Neuralgia
Upper Back Pain
Vertebral Body Fractures
Vertebral Compression Fractures or VCF's
Whiplash pain
Other Chronic Pain Condition
I'm Seeking the Following Treament
Adhesiolysis
Caudal Steroid Injection
Celiac Plexus Block
Cervical Steroid Epidural Injection or CESI
Cervical Sympathetic Nerve Block
Continuous Catheter Nerve Blocks
Disc Dekompressor
Disc Denervation
Discogram
Discography
Epidural Steroid Injection or ESI
Facet Injections
Ganglion Impar Block
Head and Neck Procedures
IntraDiscal Electrothermal Therapy or IDET
Intrathecal Pump Therapy
Joint Injections
Lysis of Adhesions
Lumbar Sympathetic Nerve Block
Neuromodulation
Medial Branch Blocks
Medication Management
M.I.L.D.
Occipital Nerve Block
Percutaneous Discectomy
Peripheral Nerve Stimulation or PNS
Racz Procedure
Radiofrequency Ablation or RFA
Rhizotomy
Sacral Nerve Stimulation (SNS)
Sacroiliac Joint Injections
SI Joint Injections
Sphenopalatine Ganglion Block
Spinal Cord Stimulator Implants of SCS
Splanchnic Nerve Block
Stellate Ganglion Block
Superior Hypogastric Plexus Block
Sympathetic Block
Trigeminal Nerve Block
Trigger Point Injection
Vertebroplasty
X-Ray Guided Injections
Other Chronic Pain Treatment
I Have the Following Insurance
Aetna
AARP
APWU
BCBS
Beechstreet
Cigna
Florida Work Comp
GEHA
Great West
Health First
Humana
Medicare
Secure Horizons
Tricare
UMR
United Healthcare
Other Insurance
Other Insurance (Please Specify)
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