Online Consultation Form
First we will ask you some questions about your pain condition.
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"Ever experience neck, joint or back pain-- and didn't know the solution to eliminate your pain? I would love, absolutely adore, hearing you describe in detail, the pain in your past-- didn't know you can eliminate?"
What is your current level of pain? *
Zero Pain
Extreme Pain
What is your source of pain? (check all the apply)* *
Required
What type of doctors have you seen for your pain? (check all the apply)* *
How long ago did your pain begin? *
Required
What Medication or treatments are you receiving for your pain? (check all the apply)* *
How did the pain begin? (check all that apply)* *
Required
Check any of the following tests you have had for this condition. (check all that apply)* *
Have you had any surgeries related to your existing pain?* *
Required
Have you had any of the following treatments /procedures? (check all that apply)* *
Does pain increase with: *
Required
Do you have weakness to your: *
Are you on medications? *
Required
Have you been given a DIAGNOSIS? What was it? *
How serious do you view your condition?* *
I can live with it
I need your help!
Are you seriously looking for a solution? *
Required
Would you like to receive a FREE PDF Copy of Dr. Moyal's latest book - Secrets of a Non-Surgical Physician Revealed "Get Out of Pain in 3 Easy Steps!" *
If there was away Dr. Moyal could meet with you and review your case - would like to schedule a review consultation with him? *
What Is Your First Name?* *
What is your Last Name?* *
What is your best email address? (used to send treatment qualification information) *
What Is Your Best Contact Cell Phone Number - Please Input Your Area Code Followed By Your Phone Number With NO SPACES, No Dashes, Or Parentheses* *
What Is Your Zip Code? *
What is the best time to contact you? *
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