Take this 30-second quiz to see if you qualify for A
FREE
Pain Relief Consultation.
How long have you been experiencing pain?
*
Just Recently
0-6 Months
6-12 Months
More Than 12 Months
Where are you experiencing pain?
*
Neck Pain
Back Pain
Shoulder Pain
Knee Pain
Foot Pain
Hip Pain
Other
What have you tried in the past to get relief?
*
Medication
Physical Therapy
Chiropractic
Physician
Googled It
Others
How old are you?
*
18-24
25-34
35-44
45-54
55-64
65 & older
What type of insurance do you have?
*
Sun Life
Canada Life
Manulife
Claim Secure
Group Source
IA Group
Desjardins
Group Health
Maximum Benefit
Other
Other Insurance?
*
Green Shield
RWAM
Johnston Group
Johnson
First Canadian
GMS
Empire Life
SSQ
None of the above
No Insurance
Are you willing & able to invest in your health & wellness?
*
Yes
No
Our staff has reserved their time for people who are serious about improving their health and wellness. Will you be able to commit to this appointment after confirming the day and time with our front desk?
*
Yes
No
To better help understand your condition, please write your occupation:
Do you believe that this occupation is responsible for the pain you're in?
Yes
No
What's your full name?
*
What's your email?
*
What's your phone number?
*
By entering your phone number you are expressing consent to be contacted via SMS & call. Messaging frequency varies. Text STOP at any time to unsubscribe.
