Qualify | Axiom Therapies

First Name*

Last Name*

Email

Phone Number*

Where in your body do you frequently experience pain?* *

Do you experience reduced mobility due to your pain?

Yes
No

What previous treatment(s) have you had?*

Are you within traveling distance of the following major markets?

Untitled

Currently insurance companies do not reimburse for regenerative / stem cell therapies. Are out-of-pocket expenses a possibility for you, understanding most initial consultations are covered by insurance but specific therapies are not?* Please Note: Treatments range from $1,000 - $7,500. Axiom recommends answering "Yes" if you would like to have a consultation and would consider out-of-pocket expenses for recommended therapies. Answer "Maybe" if you would like to talk to a representative from Axiom about your case before scheduling a consultation by a physician.

Do I Qualify?