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1
2
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Immediately
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1
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Yes
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1
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Yes
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1
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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Yes
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Yes
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1
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3
4
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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Yes
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Are you currently a patient at another knee pain office or clinic?
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Yes
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When are you looking to get results?
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Immediately
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1
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3
4
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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Yes
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Are you currently a patient at another knee pain office or clinic?
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Yes
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When are you looking to get results?
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Immediately
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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4
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4
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When are you looking to get results?
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Immediately
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3
4
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7
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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Immediately
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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When are you looking to get results?
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Immediately
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1
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Yes
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Immediately
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1
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Yes
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Yes
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Immediately
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1
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3
4
5
6
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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Yes
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Are you currently a patient at another knee pain office or clinic?
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Yes
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Immediately
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1
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3
4
5
6
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Do You Currently Take Any Medication To Deal With Pain / Discomfort
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Yes
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1
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3
4
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare with supplemental coverage
Medicare with secondary coverage
Blue Cross Blue Shield
Cigna
other insurance
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
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Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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1
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Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white, and blue card)
Medicare with Supplemental Insurance
Medicare
United Healthcare AARP
Blue Cross Blue Shield
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*
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*
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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Step
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Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white, and blue card)
Traditional Medicaid (disability)
Medicare Advantage Plan (Medicare through a commercial provider)
Peachstate (Medicaid)
Ambetter
Wellcare (Medicare + Medicaid)
Blue Cross Blue Shield, Anthem
Aetna
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United Healthcare
Other insurance / I'm not sure who my primary insurance provider is
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*
*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Traditional Medicare
Medicare plus Secondary Insurance
Medicare plus Supplemental Insurance
Aetna
United Healthcare
United Healthcare AARP
Cigna
Blue Cross Blue Shield
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*
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*
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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Step
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white, and blue card)
Medicare with supplemental insurance
Medicare with secondary insurance
Medicare Advantage Plan
Please note that we are ONLY in-network with original Medicare (red, white, and blue card). We are not in-network with any commercial insurances such as Blue Cross, Aetna, Cigna, United Healthcare, or any other commercial insurance plans.
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
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*
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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Step
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white, and blue card)
Medicare with supplemental insurance
Medicare with secondary insurance
other insurance / I'm not sure
**Please note that our office is currently ONLY in-network with traditional Medicare (red, white, and blue card).
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
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*
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*
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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Step
1
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Medicare
BlueCross BlueShield
Aetna
Cigna
Hap
Humana
Tricare
Others
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*
*
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Step
1
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Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare with supplemental coverage
Medicare with secondary coverage
Blue Cross Blue Shield
Cigna
other insurance
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
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*
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*
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step
1
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7
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Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
United Healthcare
Aetna
Humana
Blue Cross Blue Shield
Medicare
Medicare Advantage Plans
Medicaid
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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Step
1
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare plus supplemental insurance
Medicare plus secondary insurance
Aetna
AvMed
Blue Cross Blue Shield
Cigna
GEHE
Humana
Humana Choice
United Healthcare
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*
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*
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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1
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Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Regence
Cigna
Aetna
Humana
DMBA
UMR
Select Health (we DO NOT accept Select Health Advantage Plans)
Medicare Advantage Plan through Regence, Cigna, Aetna, Humana
Select Advantage
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white, and blue)
Medicare with Supplemental or Secondary Coverage (Plan F, Plan G)
Medicare Advantage Plan
United Healthcare
Cigna
Aetna
other insurance
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
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*
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*
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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*
Hip Pain
Shoulder Pain
Elbow Pain
Pain and other Joints
Rate Your Daily Joint Pain from 1-10
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently seeking any surgical or non-surgical care for joint pain?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
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*
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*
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*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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Step
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Federal Medicare
Humana Medicare
Aetna Medicare
Blue Cross Blue Shield
Aetna
Humana
Cigna
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*
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*
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Between Noon and 2 PM
Between 2 PM and 5 PM
After 5 PM
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare with supplemental or secondary insurance (Plan F, Plan G)
Blue Cross Blue Shield (of New Hampshire or Massachusetts)
United Healthcare
Cigna
Humana
Tricare
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*
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*
When is the best time to reach you?
*
Before Noon
Between Noon and 2 PM
Between 2 PM and 5 PM
After 5 PM
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Federal Medicare part B
Blue Cross Blue Shield
Anthem Blue Cross Blue Shield
Carefirst
Aetna
Priority Partners
Johns Hopkins Community Plan
Cigna
Coventry
AARP
United Health Care
Tricare for Life
Humana
Union Insurance (Steam Fitters, Council of Carpentry)
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*
*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare Advantage Plan
Humana
Humana Gold HMO
United Healthcare / AARP
Wellcare
RR Medicare
Blue Cross Blue Shield
Anthem
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*
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*
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*
Before Noon
Between Noon and 2 PM
Between 2 PM and 5 PM
After 5 PM
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare with supplemental or secondary insurance (Plan F, Plan G)
Medicare Advantage Plan
Cigna
United Healthcare
Blue Cross Blue Sheild
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*
When is the best time to reach you?
*
Before Noon
Between Noon and 2 PM
Between 2 PM and 5 PM
After 5 PM
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare with supplemental insurance
Medicare with secondary insurance
Medicare Advantage Plan (Medicare as secondary insurance)
Aetna
Blue Cross Blue Shield
Cigna
Humana
Tricare
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*
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*
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*
*
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Step
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare with supplemental insurance
Medicare with secondary insurance
Aetna
Other commercial insurances
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
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*
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*
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*
*
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×
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare (red, white and blue card)
Medicare with supplemental insurance
Medicare with secondary insurance
Blue Cross, Aetna, Cigna, Tricare, Humana, or another commercial insurance
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
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*
*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Traditional Medicare (red, white and blue card)
Medicare with supplemental insurance
Medicare with secondary insurance
other insurance
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
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*
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*
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*
*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
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Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare
Medicare plus secondary insurance
Medicare plus supplemental insurance
Blue Cross Blue Shield
United Healthcare
United Healthcare AARP
Cigna
Humana
Aetna
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
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Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare
Medicare plus secondary insurance
Medicare plus Supplemental Insurance (Plan F)
Medicare Replacement Plan
United Healthcare
United Healthcare AARP
Humana
Aetna
TriCare
Cigna
MedCost
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*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare
Medicare plus secondary insurance
Medicare plus supplemental insurance
Blue Cross Blue Shield
United Healthcare
United Healthcare AARP
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Humana
Aetna
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*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Traditional Medicare
Medicare + Supplemental Insurance
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I don't have insurance / I'm a cash patient
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*
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Original Medicare
Medicare Plus Secondary Insurance
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*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Traditional Medicare
Medicare plus Secondary Insurance
Medicare plus Supplemental Insurance
Aetna
United Healthcare
United Healthcare AARP
Cigna
Blue Cross Blue Shield
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*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Traditional Medicare
Medicare plus Secondary Insurance
Medicare plus Supplemental Insurance
TriCare
Aetna
Cigna
Blue Cross Blue Shield
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Ambetter
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*
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*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Traditional Medicare
Medicare plus Supplemental Insurance
Medicare plus Secondary Insurance
United Healthcare
Humana
Blue Cross Blue Shield
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*
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Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Traditional Medicare
Medicare plus Supplement
Medicare plus Secondary
I don't have insurance / I am a cash patient
Medicare Advantage Plans
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TriCare
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*
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Federal Medicare
Medicare Plus
United Healthcare
United Healthcare AARP
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*
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Medicare Part B
Commercial PPO plan with out-of-network benefits
I don't have insurance / I'm a cash patient
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*
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Federal Medicare part B
Commercial Insurance with out of Network Benefits
I don't have insurance / I'm a cash patient
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*
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Federal Medicare part B
Blue Cross Blue Shield
Anthem Blue Cross Blue Shield
Carefirst
Aetna
Priority Partners
Johns Hopkins Community Plan
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AARP
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*
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*
Ulcers
Deep, bleeding wounds
More than one type
Are these wounds CHRONIC, meaning that you experience them constantly?
*
Yes
No
On a scale of 1-10, please rate your daily pain:
*
1
2
3
4
5
6
7
8
9
10
How long have you been experiencing chronic foot wounds caused by diabetes?
*
Less than 1 year
More than 1 year
More than 5-10 years
When are you looking to get results?
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Immediately
2 weeks
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This treatment is only covered by Federal Medicare; are you currently a Federal Medicare patient?
*
Yes
No
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*
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Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
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Medicare Plus
United Healthcare
United Healthcare AARP
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*
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Federal Medicare
Medicare Plus
United Healthcare
United Healthcare AARP
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*
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Meniscal Tears
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Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
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*
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BlueCross BlueShield
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Others
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Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Federal Medicare
Humana Medicare
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Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
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*
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Knee Injury
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*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
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Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
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Federal Medicare
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I don't have insurance / I would be a cash patient
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*
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Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
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*
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Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
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7
14%
TAKE OUR 10 SECOND QUIZ
Find Out If You Qualify for a FREE Consultation / Knee Assessment
Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Federal Medicare
Federal Medicare with Secondary Coverage
Medicare Advantage Plans
United HealthCare
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step
1
of
7
14%
TAKE OUR 10 SECOND QUIZ
Find Out If You Qualify for a FREE Consultation / Knee Assessment
Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Blue Cross Blue Shield
United Health Care
UHC / AARP
Federal Medicare
Federal Medicare with secondary coverage
No Insurance / I am a cash patient
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step
1
of
7
14%
TAKE OUR 10 SECOND QUIZ
Find Out If You Qualify for a FREE Consultation / Knee Assessment
Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
BlueCross BlueShield
United HealthCare
Medicare
Others
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step
1
of
7
14%
TAKE OUR 10 SECOND QUIZ
Find Out If You Qualify for a FREE Consultation / Knee Assessment
Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Traditional Medicare
Medicare + Supplemental Insurance
Medicare + Secondary Insurance
Aetna
Blue Cross Blue Shield
I don't have insurance / I am a cash patient
WellCare
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step
1
of
7
14%
TAKE OUR 10 SECOND QUIZ
Find Out If You Qualify for a FREE Consultation / Knee Assessment
Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Medicare
BlueCross BlueShield
Aetna
Cigna
United HealthCare
Others
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step
1
of
7
14%
TAKE OUR 10 SECOND QUIZ
Find Out If You Qualify for a FREE Consultation / Knee Assessment
Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Medicare
BlueCross BlueShield
Aetna
Cigna
United HealthCare
Others
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step
1
of
7
14%
TAKE OUR 10 SECOND QUIZ
Find Out If You Qualify for a FREE Consultation / Knee Assessment
Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Medicare
BlueCross BlueShield
Aetna
Cigna
Hap
Humana
Tricare
Others
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step
1
of
7
14%
TAKE OUR 10 SECOND QUIZ
Find Out If You Qualify for a FREE Consultation / Knee Assessment
Which Condition Are You Currently Experiencing?
*
Meniscal Tears
Osteoarthritis
Bone on bone
Knee Injury
Rate Your Daily Pain
*
1
2
3
4
5
6
7
8
9
10
Do You Currently Take Any Medication To Deal With Pain / Discomfort
*
Yes
No
Are you currently a patient at another knee pain office or clinic?
*
Yes
No
When are you looking to get results?
*
Immediately
2 weeks
60 days
90 days and up
What type of Insurance do you have?
*
Medicare
BlueCross BlueShield
Aetna
Cigna
Hap
Humana
Tricare
Others
Thank you for providing this case information. Please complete the form below to send these assessment results to our team:
Name / Surname
*
First
Last
Email
*
Phone
*
*
I acknowledge that upon submitting this assessment I will be contacted via phone, email, or SMS by a treatment coordinator with a follow-up discussion within 24-48 hours.
×
Step 1 of 2: Please fill out the form below ....
Select below the session you would like to attend:
*
Wednesday, November 13th at 6:45 PM @ Double Tree by HIlton, Bloomfield Hills 39475 Woodward Ave, Bloomfield Hills, MI 48304
Topic: Non-Surgical Joint Pain Relief
*
Topic: Non-Surgical Joint Pain Relief
Please enter your information below for event verification:
First and Last Name
*
Email Address
*
Mobile Number
*
Guest Name
*
Please tell us how we can help you:
What Condition / Symptoms Are You Currently Experiencing?
How Is This Condition / Symptoms Affecting Your Daily Life?
When Are You Looking To Get Results?
When would you like us to call you to confirm?
*
9:00AM-Noon (EST)
Noon-2PM (EST)
2PM-5PM (EST)
As soon as possible
*
I acknowledge that all the information above is correct and upon submitting this form a patient coordinator from the clinic may call for follow up questions.
×
Step 1 of 2: Please fill out the form below ....
Select below the session you would like to attend:
*
Tuesday, November 19th at 6:30 PM @ Nulife Medical, 31333 Southfield Road, Suite 130 Beverly Hills, MI 48025
Topic: Non-Surgical Knee Pain Relief
*
Topic: Non-Surgical Knee Pain Relief
Please enter your information below for event verification:
First and Last Name
*
Email Address
*
Mobile Number
*
Guest Name
*
Please tell us how we can help you:
What Condition / Symptoms Are You Currently Experiencing?
How Is This Condition / Symptoms Affecting Your Daily Life?
When Are You Looking To Get Results?
When would you like us to call you to confirm?
*
9:00AM-Noon (EST)
Noon-2PM (EST)
2PM-5PM (EST)
As soon as possible
*
I acknowledge that all the information above is correct and upon submitting this form a patient coordinator from the clinic may call for follow up questions.
×
Step 1 of 2: Please fill out the form below ....
Select below the session you would like to attend:
*
Thursday, November 7th at 6:30 PM @ Nulife Medical, 31333 Southfield Road, Suite 130 Beverly Hills, MI 48025
Topic: Non-Surgical Knee Pain Relief
*
Topic: Non-Surgical Knee Pain Relief
Please enter your information below for event verification:
First and Last Name
*
Email Address
*
Mobile Number
*
Guest Name
*
Please tell us how we can help you:
What Condition / Symptoms Are You Currently Experiencing?
How Is This Condition / Symptoms Affecting Your Daily Life?
When Are You Looking To Get Results?
When would you like us to call you to confirm?
*
9:00AM-Noon (EST)
Noon-2PM (EST)
2PM-5PM (EST)
As soon as possible
*
I acknowledge that all the information above is correct and upon submitting this form a patient coordinator from the clinic may call for follow up questions.
×
Step 1 of 2: Please fill out the form below ....
Select below the session you would like to attend:
*
Thursday, November 14th at 6:30 PM @ Nulife Medical, 31333 Southfield Road, Suite 130 Beverly Hills, MI 48025
Topic: Non-Surgical Knee Pain Relief
*
Topic: Non-Surgical Knee Pain Relief
Please enter your information below for event verification:
First and Last Name
*
Email Address
*
Mobile Number
*
Guest Name
*
Please tell us how we can help you:
What Condition / Symptoms Are You Currently Experiencing?
How Is This Condition / Symptoms Affecting Your Daily Life?
When Are You Looking To Get Results?
When would you like us to call you to confirm?
*
9:00AM-Noon (EST)
Noon-2PM (EST)
2PM-5PM (EST)
As soon as possible
*
I acknowledge that all the information above is correct and upon submitting this form a patient coordinator from the clinic may call for follow up questions.
×
×
×
Step
1
of
6
16%
Current Condition
*
Osteoarthritis
Knee Injury
Bone on Bone
I'm Not Sure
Which Knee Are You Having Pain?
*
Left
Right
Both
Rate Your Daily Knee Pain
*
1-3 (Mild Pain)
4-7 (Moderate Pain)
8-10 (Extreme Pain)
Have You Had Knee Surgery Previously?
*
No
Yes
Do You Take Pain Medicine Daily?
*
Yes
No
Do You have Medicare Insurance?
*
No
Yes
Have You Been Told You Need Knee Surgery?
*
Yes
No
First Name
*
Last Name
*
Phone #
*
Email
*
