📍 20 N 29th St. Fort Dodge, IA 50501

Are you taking pain medications like Gabapentin or Lyrica to help with the pain? *

Yes

No

How long have these symptoms been bothering you? *

Less than 1 year

1 - 3 years

4 - 6 years

6+ years

Do you have any of the following? *

Diabetes

Alcoholism

Undergone Chemotherapy

None of the above

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

Below 650

650-700

700-750

750+

What is your Zip code? (this helps us know that we are reaching people in our area)

We are located in 20 N 29th St., Fort Dodge IA 50501, is this commutable to you? *

Yes

No

Full Name *

What is your best email address? *

What is your best phone number? *