Book Appointment

Patient Questionnaire

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

Gender: MaleFemale


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 , 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.