Find out if you Qualify for our Neuropathy Relief Program
Please fill out the form below and submit.
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Q1 - How long have you had neuropathy symptoms? *

Less than 6 months?

6-12 months

1-3 years

3 + years

Q2 - What symptoms are you experiencing? *

Numbness

Burning / Sharp pain

Tingling

Balance Issues

None of These

Q3 - How severe is your condition? *

Mild

Moderate

Severe

Q4 - If you are a candidate, are you open to investing in a program to improve your condition? *

Yes

Maybe

No

Q5 Do you currently have Medicaid? - We do not accept Medicaid, but we do offer affordable payment options for those who qualify. *

Yes

No

If you qualify, we may review financing options that do NOT affect your credit score.

Name *

First

Last *

Last

Address *

City - State - Zipcode *

Email *

Phone *

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Contact us today at 732-867-8030
142 NJ-35 #107, Eatontown, NJ 07724
Email dr.charles@neuropathyreliefproject.com
Panda Physical Medicine LLC