Consult Us

First Name *

Email *

Did one of us specifically refer you to this request form from a direct message? (this question is NOT required)

Kobra Bengal

What's your age and sex? *

Enter Today's Date *

Where is your pain located? *

When did these issues begin? *

How did this injury happen? *

Describe your pain. *

Sharp Dull Constant Intermittent Numbness, fully or decreased feeling Tingling

Have you seen anyone for this injury? Did it help? *

What treatments have you had for it? (meds, injection, rehab from PT or DC, anything you can think of) *

What movements or activities have you been forced to stop because of your pain? *

What movements or activities have you found that DECREASE your pain? *

Have you had any imaging done (xray, MRI, etc). What were the results? *

Are there any activities that you'd like to resume doing comfortably now, that you can't do now? *

Give me the details of your current exercise program/routine. Are you training for anything specific? *

What can I do for you today that will help you out the most? *

So there are no surprises, check "I acknowledge" since the assumption is you've made it this far and you want to work with us. As much as we LOVE to chat to people about injuries, we do have bills to pay. We will review the info you provided and determine if our products and services are the right solution for you. If we don't think we are the right fit, we can help refer you to someone else in our network. *

I acknowledge