Wufoo

Initial Consultation Request

We need the following information from you in order to schedule a complementary consultation with the doctor. The purpose of the initial consultation is to find out whether one may be a good candidate for Spinecor treatment. The consultation is absolutely without charge or obligation.

Please try to fill out below information as accurately as possible. Any information you may share here will not be used for anything other than above description or be shared with anyone.

(The consultation is llimited to 30 per month. Once the number is reached, this form will not work until next month. If this happens, you may wait until next month or call us at (877) 469-6663 and we may schedule you if canellation exists.)

What is your name? * First Last
You must be 18 years old or older in order to request consultation. If you are a minor, please have your legal guardian or one of your parents fill out the form.
What is your email address? *

We need your email address as a back up contact. We'll attempt to contact you by email if we cannot reach you by phone.
What is the best phone number to reach you? * ### - ### - ####
This is the primary method which we'll try to reach you.
I am requesting a consultation for:
What is your treatment goal or expectation? Check all that applies.
I need symptomatic relief from pain caused by scoliosis I need stability and support so that my curve does not progress further I want to achieve stable correction
From this point on, please enter information regarding whom you are requesting consultation for.
How old are you? *

Please enter the age of the person with scoliosis whom you are requesting consultion for.
Please enter your Risser Sign, curve mearsurement, location of the curve. If you are a female and under 18, please enter the date of menarche. *
If you do not have the information you may skip them. However, please try your best to answer as much as you can.

Risser Sign: (0-5) Bone maturity sign
Curve Measurement and Location:
e.g. Thoracic 38, Lumbar 23
Menarche: Date of your first menstruation
If you have received any treatment, please enter below. (e.g. Chiropractic Rehab, Physical Therapy, Brace: what type?, Surgery or any other conventional or alternative therapy) *
Please enter your address below. *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

We need your address in order to refer you to the closest provider if treatment is indicated. Referrals are only made at the request of the patient or legal guardian.
Do Not Fill This Out

Wufoo Powered

Wufoo

From this point on, please enter information regarding whom you are requesting consultation for.