Complete This Survey To Discover If Our Neuropathy Protocol Treatments Are Right For You.

Here is what you should expect:

This Neuropathy Protocol Survey will provide our Doctors with some basic information about your condition so we can determine if you are a good candidate for an initial consultation and exam.

This survey is not intended to diagnose or give you any treatment advice concerning your condition.

Your responses to this survey will be reviewed by our Doctors and support team.

If we feel you may be a good candidate, someone from our team will reach out to you to answer any questions you may have and to help you schedule a consultation.

There is absolutely no obligation to schedule a consultation after this survey.

Once you have completed the survey you will have the option to schedule a call from our staff at a time that is convenient for you.

Thank you for your time,
The Team at Axiom Chiropractic & Neuropathy

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Neuropathy Protocol Survey

Before we begin, please provide your contact information.

If you are a good candidate, someone from our team will contact you within one business day.

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Neuropathy Protocol Survey

Which of the following neuropathy symptoms are you currently experiencing?  

Please select all that apply.

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Neuropathy Protocol Survey

Duration of Condition:

How long have you been experiencing your symptoms?

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Neuropathy Protocol Survey

Severity of Condition:

On a scale of 1-10 How would you rate the severity of your symptoms?

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Neuropathy Protocol Survey

Previous Treatments:

What have you done in the past to treat your neuropathy?

Please select all that apply.

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Neuropathy Protocol Survey

On a Scale of 1 – 10 with 1 being the lowest level of success and 10 being the highest, How well have you been able to manage your symptoms with your past treatments?

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Neuropathy Protocol Survey

Treatment Goals and Expectations:

What are your primary goals and expectations from a treatment for neuropathy?

Please select all that apply.

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Neuropathy Protocol Survey

We offer some of the most advanced therapies available.

In some cases, we offer flexible financing options for individuals who want to take advantage of these therapies.

What best describes your current credit profile?

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Neuropathy Protocol Survey

Comments and Concerns:

Is there any additional information you would like to share with the Doctor before we contact you?

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Neuropathy Protocol Survey

Someone from Axiom Chiropractic & Neuropathy will be contacting you from

(605) 275-2010

regarding your survey and to help you with scheduling an appointment. We can't wait to speak with you!

By Clicking this box you give consent to be contacted by Axiom Chiropractic & Neuropathy via SMS Texting, Email, and Phone

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