Your assessment has been received! One of our team members will contact you to schedule an appointment. if you have any questions, please give us a call at 407-412-5030.

Please add the following questions

1. 1) What is your name?
2. 2) On a scale of 1 to 5, how painful is your knee pain?
3. 1. a – No pain
   2. b – A little annoyng pain
   3. c – nagging and uncomfortable pain
   4. d – intense and miserable pain
   5. e – Worst possible, unbearable, excruciating pain
4. 3) In two or three sentences, please tell us what makes you a good candidate for Stem Cell Therapy?
5. 4) How serious are you about finding a solution to your knee pain?
6. 1. a – Just searching nad looking ofr options
   2. b – very interested and looking at 3nd opinion
   3. c – very serious – i am getting treatment in the next 6o days.
   4. d – other
7. 5) Our Stem Cell Therapy options range up to $5000. What best describes your ability to pay for stem cell therapy?
8. 1. a – I am aware of the cost but can’t pay for them right now.
   2. b – I can pay the full amount up front
   3. c – I would consider a payment plan if the Stem Cell Therapy is right for me.
9. 6) Do you have medical insurance
10. 1. a – I have medical insurance
    2. b – I have medicaid / medicare
    3. c – I dont have medical insurance
11. 7) what is the best way to reach you?
12. 1. a – phone
    2. b – email
13. 8) what is the best number to reach you?
14. 9) What is teh best tim e to reach you?
15. 1. a – morning
    2. b – Mid-day afternoon
    3. c – Evening
16. 10) upon receiving your application, we will contact you to schedule a date and time for your consultation. Do you commit to making your appoinment?
17. 1. a – Yes, I commit to showing up for my scheduled consultation.
    2. b – other.