By completing the above survey, I consent to Mainstay Medical reviewing this limited health information about me, providing an initial, preliminary assessment about whether ReActiv8 may be a suitable therapy for me, and offering to contact me to provide more information. I understand this does not represent medical advice, opinion, diagnosis, or services in any way, and I must consult with my physician or other health care provider for an actual determination about this product. I also understand that, by providing this information, I am not guaranteed or promised any service or product, nor a final or complete assessment on whether ReActiv8 may be appropriate for my low back pain.