Submit your application below and our medical specialist will contact you shortly to set up an appointment. Submit your application online. Name * First Name Last Name Phone (###) ### #### Email * Briefly describe what your current challenges are. On a scale of 1 - 10, 10 being awful, how would you rate your pain today? 1 2 3 4 5 6 7 8 9 10 Why do you believe this treatment will help you? If you are under the care of a physician, please enter their name and telephone number here. Have you discussed this treatment with him/her? Yes No Thank you. Your application has been submitted! Please allow 24 hours for your application to be reviewed prior to someone from our team contacting you. Thank you!