Consultation Request

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Locations on the East and West Coast - Call Us Today! Irvine, CA 1 (949) 640-6675 | Naples, FL (239) 420-7447

Upon completing this form you will receive an email with further instructions. There is a nominal fee of $50 for the MRI evaluation or $100 for a one on one phone consultation with Dr. Mork.

If for whatever reason we are not able to reach you or you wish to speak to us right away please call us asap at: 949-640-6675

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Name*
First Last
Email*

Please enter your valid email address.
Phone*
Please enter your phone number so our staff can followup with you.
How did you hear about Dr. Mork?*
Female
Male
Please click where you feel the pain
Please click where you feel the pain

Do you have a recent MRI (less than a year old) ?
- Yes
- No
Is your main problem pain, numbness or weakness ?
- Numbness
- Weakness
- Other
How long have you been bothered ?
- Months
- Years
Has your pain been getting worse recently?
- Yes
- No

Are you being awakened at night ?
- Yes
- No
- Sometimes
Main reason that you called Dr Mork?
- Laser surgery
- Endoscopic surgery
- Avoid a fusion
- Other
Had previous surgery on your spine ?
- Yes
- No
Comments
Back pain position
Front pain position
Back pain position
Front pain position
Please upload a copy of your MRI
Comments
This field is for validation purposes and should be left unchanged.