Book Appointment

Patient Questionnaire

Please fill the form below and submit to us, to get started.


Please Answer These Simple 8 Questions (It Should Not Take More Than 1-2 Minutes)


1. DO you have a history of back problems (slipped disk, or spine surgery, or damage to your spinal chord ? NOYES


2. DO you have a history of Anemia? NOYES


3. Are you on any blood thinners ? (Aspirin, Plavix, Xaralto, Eliquis, Lovenox, Pradaxa) or any similar ? NOYES


4. Do you have a history of a bleeding disorder? (Hemophilia ?) NOYES


5. Are you pregnant? NOYES


6. Do you have any allergies to skin disinfectants (peroxide, detail, or rubbing alcohol?) NOYES






Please make sure you have entered the correct phone number and a member of our team will contact you to setup an appointment.


Please email floridacupping@gmail.com with the subject APPT and we will contact you to set up an appointment.

  • Name:
  • Phone number:
  • Email:

Be prepared to answer the following questions when called.

  • 1. DO you have a history of back problems (slipped disk, or spine surgery, or damage to your spinal cord ?
  • 2. DO you have a history of Anemia?
  • 3. Are you on any blood thinners ? (Aspirin, Plavix, Xaralto, Eliquis, Lovenox, Pradaxa) or any similar?
  • 4. Do you have a of a bleeding disorder? (Hemophilia ?)
  • 5. Are you pregnant?
  • 6. Do you have any allergies to skin disinfectants (peroxide, detail, or rubbing alcohol?)