We're located at 17221 SE Division St, Portland OR 97236
Call Us Today:
971-396-3042
Congrats on Claiming our New Patient Special for only $49!
Fill Out Our Quiz To See If You Quality For Our Treatment
Who are you filling this out for?
*
Myself
Husband
Wife
Daughter
Son
Other
What back pain symptoms are you experiencing?
*
Sharp pain in the back
Trouble standing or sitting
Back muscle spasms
Pain when walking short distances
Some of these above
All of these above
On a scale of 1-5, 5 being "excruciating", how bad is the pain in your back?
*
1
2
3
4
5
How long have these symptoms been bothering you?
*
Less than 1 year
1-3 years
4-6 years
6+ years
Have you been diagnosed with any of the following conditions?
*
Herniated disc
Degenerative disc disease
Sciatica
Stenosis
None
On a scale from 1-10, how serious are you about getting this treatment?
*
0-2
3-6
7-9
10 I Want This Treatment!
Our address is 17221 SE Division St, Portland OR, 97236. Is this commutable for you?
*
Yes
No
Please Re-verify Your Full Name
*
Please Re-verify your Phone Number
*
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
© 2024
Pacific Chiropractic & Wellness Center.
All Rights Reserved.
