Please fill the form below and submit to us, to get started.
Gender: MaleFemale
1. DO you have a history of back problems (slipped disk, or spine surgery, or damage to your spinal chord ? NOYES , if Yes please write more in the box below
2. DO you have a history of Anemia? NOYES , if Yes please write more in the box below
3. Are you on any blood thinners ? (Aspirin, Plavix, Xaralto, Eliquis, Lovenox, Pradaxa) or any similar ? NOYES , if Yes please write more in the box below
4. Do you have a history of a bleeding disorder? (Hemophilia ?) NOYES , if Yes please write more in the box below
5. Are you pregnant? NOYES
6. Do you have any allergies to skin disinfectants (peroxide, detail, or rubbing alcohol?) NOYES , if Yes please write more in the box below
8. Requested Appt date:
Please make sure you have entered the correct phone number and a member of our team will contact you to setup an appointment.
If you have an urgent need for a sooner appointment, please email us : floridacupping@gmail.com with URGENT in the subject field.