Back Bubble Personal Evaluation
Clients are advised to try both positions to see which works best for them. However, for significant lower back problems that have been diagnosed by your trusted physician, we recommend you fill out the evaluation form below.


Simply call us when you begin using your Back Bubble® Lumbar Spinal Decompression product, and we will have this information on hand to help guide you to the best results.

Please fill in all of the areas including phone number and email address so that when your Back Bubble arrives we can communicate with you to ensure the very best results.


Privacy Policy

Any information you supply us is held in strict confidentiality. We only use the information to help guide you with The Back Bubble® Lumbar Spinal Decompression product.


Evaluation Form
 
Name:

Required Field*
Please designate your time zone:
[pacific, mountain, or eastern]
E-mail address:

Required Field*
Telephone number:

Required Field*
Address:
Address line 2:
City:
State / province:
Zip or postal code:
Country:

Rate your pain level 1-10: [10 being extreme]
— Morning: — Noon: — Evening:
Did your doctor diagnose the problem?
[yes/no]
Have you had lower back surgery?
[yes/no]
How long have you had lower back pain?
— Years: — Months:

 


Doctor's diagnosis:
[Check one or more of the boxes below]
Lower Back Pain
Leg Pain (Sciatica)
Buttock Pain
Degenerative Disc Disease
Arthritis
Subluxation
Disc Bulge or Herniation
Muscle Spasms
Facet Dysfunction
Scoliosis
Stenosis
Muscular Pain or Strain

Other?

 

Where is your pain?

Check the boxes on the right to indicate where it is you have your back pain
[Atlas/Axis]
..........
[Cervical Spine]
..........
[Upper Thoracic]
..........

[Lower Thoracic]
..........
[Upper Lumbar]
..........
[Lower Lumbar]
..........
[Sacrum]
..........
[Coccyx]
..........


Age: Height: Sex: Weight:
years only feet/inches male/female lbs.

What medical insurance covers your lower back problem?
Workers' Compensation Medicare PPO Other
Point of Service Med Pay HMO No Insurance


If you have answered all the questions above, please click the SUBMIT button below and place your ORDER NOW.