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Tell Us More About Your Condition

Complete This 30-Second Survey To Reserve Your Voucher

Have you already been diagnosed with peripheral neuropathy? *

Yes

Are you currently using any medications or therapies for your neuropathy (like Gabapentin, Lyrica, or Cymbalta or others)? *

Yes

What is the main source of your symptoms? (Please check all that apply.) *

Hands

Feet

Arms

Legs

Back

Some of the above

All of the above

Where did your symptoms start? *

Hands

Feet

On a scale of 1-5, where 5 is the highest, how excruciating are your symptoms? *

5 - Excruciating: Unbearable intensity, completely disrupts normal activity.

4 - Severe: Intense stress, significantly hinders activities.

3 - Uncomfortable: Persistent discomfort affects daily life.

2 - Moderate: Some daily disruption.

1 - Mild: Slightly stress, minimal impact.

Have you noticed any progression or worsening of your symptoms overtime? *

Yes

On a scale of 1-5, where 5 is the highest, how would you rate your commitment to taking care of your pain right now? *

5 - All-In: Fully committed to a comprehensive, intensive approach.

4 - Eager: Strongly ready for active, significant measures.

3 - Ready: Willing for regular efforts and moderate changes.

2 - Hesitant: Some openness, but mostly reluctant to extensive actions.

1 - Resistant: Only open to minimal efforts, largely unwilling.

Assuming we can help you, treatments typically aren't fully covered by insurance. If there was a low monthly payment to get the help that you needed, is that something that could possibly work for you? *

Yes

Maybe

Financing options are available based on your credit. Which option best describes your credit? *

Excellent Credit (Above 750)

Great Credit (700-750)

Average Credit (650-700)

Poor Credit (Below 580-650)

Bad Credit (Below 580)

Please re-verify your Full Name. *

Please re-verify your Phone Number. *

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For questions and for faster scheduling, call (631) 769-3846

Brodbeck Chiropractic Regenerative Medicine

(631) 769-3846

5976 NY-25A Wading River, NY 11792

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