ONLY for individuals who are serious about resolving sciatica or back pain

1.This application is for the RehabFix Low Program to help us learn how to truly help you get pain-free!

2. VERY IMPORTANT: Making an investment in your health is a big deal. You simply can't live a normal life with low back pain. This is something that will change your life forever, and should be taken seriously! The value you will gain in your life from this will be worth 100x anything you pay.

First Name *

Last Name *

Email *

Phone *

State/Country *

Age (this can relate to different spine conditions) *

Thanks for that info! So, how long have you been suffering with low back pain, and what happened (if anything) to cause it? *

What have you tried up until this point for your low back? *

Why do you think these efforts have been ineffective? *

Do you have sciatica? *

Yes

No

Have you been diagnosed with a disc herniation? *

Yes

No

The RehabFix Low Back Program is a 6 month commitment to achieve a bullet-proof low back. You need to be self-motivated! Is this a duration you can handle? *

We receive many applications and some applicants are more motivated than others. Are you a committed, highly motivated individual that is seriously ready to commit to a plan and will value the impact that a program and guidance from a low back expert can have on your life? *

Yes, I am a serious applicant and am ready to commit to something that will provide results.

No, I am still unsure of what I want to do.

Are you currently employed and/or capable of investing into professional medical care? *

Yes

No

Grant cares about your recovery! There will be a small fee for assessment time. The results of your assessment will determine the cost for your program. A program cost quote before assessment will set an expectation prematurely before all the facts are examined. We have also found that human nature may overshadow the primary focus of gaining health and livelihood back with feeling unworthy of the cost. For these reasons, RehabFix program costs will not be discussed until AFTER all information is examined and you experience encouraging results during the assessment process. *

I Understand

What does your dream life look like without low back pain? *

What is most important to you from Grant's team for your success in this program to achieve your goals without low back pain?

Is there any additional information you would like us to know?

If referral or 'other', please supply name/more detail

Proud of you for taking this step! We will speak with you soon!

***ONLY for individuals who are serious about resolving sciatica or back pain***

ONLY for individuals who are serious about resolving sciatica or back pain