Request an Appointment to
the Neck & Back Medical Center

Please fill out the form below so we can assist you. Required fields have a light blue background.

Contact Information:
Name
Address
City
State
Zipcode
Country
Phone
Email
Medical Information:

Please indicate if you have experienced any of the following (check all that apply):
Unsuccessful previous neck or back surgery, especially with recurrent or worse symptoms
Back pain
Neck pain
Sciatica (leg pain)
Arm pain
Arm or leg numbness
Inability to walk more than one city block due to leg pain.
Inability to work due to disabling spine pain
Night-time pain which awakens you from sleep
Recommended for surgery by another surgeon
Loss of bowel or bladder control. (Please call 911. This is an emergency)

Comments and Additional Information:
 

Thank you for your interest in the Neck and Back Medical Center.
Neck and Back Medical Center, Inc.
26072 Merit Circle, Suite 119 • Laguna Hills, CA 92653 • 949-859-6600
Spinal Decompression, De-compression, MedX Therapy, MedXTherapy, Med X Therapy
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