601-688-8040

Thanks For Scheduling Your Appointment

In order for us to best prepare for your appointment, please complete the brief survey below

Do you currently experience peripheral neuropathy pain, burning, or numbness? *

Yes

No

Do you currently take medications for peripheral neuropathy such as Lyrica or Gabapentin *

Yes

No

Do the doctors know what caused your neuropathy? *

Yes

No

How committed are you to fixing your neuropathy TODAY? *

Very Committed

Somewhat Committed

Neutral

Not ready to commit

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: "I will NOT miss my appointment once it is scheduled because I respect your time and I understand it's not fair for others who have scheduled in my place if I don't show up." *

Yes

No

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