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Medical History
First Name
*
Last Name
Phone Number
Which Doctor did your procedure?
*
Select an option
Dr. Louis Bojrab
Dr. John Chatas
Dr. Edward Washabaugh
Date of Birth
Date of your procedure
*
What was your PAIN SCORE BEFORE the procedure?
Select an option
1
2
3
4
5
6
7
8
9
10
What is your PAIN SCORE 2 hours AFTER the procedure
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1
2
3
4
5
6
7
8
9
10
Is that at least 80% better?
Select an option
Yes
No
Tell us how your relief is from your procedure today. Feel free to explain, since this goes to your doctor:
*
(CID : 28442)
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