First Name
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Last Name
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Email
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Phone
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What is the age of your oldest living parent or grandparent, or what was their age at the time of their passing?
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Do you have an active diagnosis?
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Yes
No
What condition(s) are you experiencing?
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What have you tried in order to solve this pain or dysfunction?
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Check all that apply to you.
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Have had to get a cortisone injection.
Have been told I need surgery.
Neck pain or back pain.
Sciatic/Radiating Pain into arms/hand or Legs/Feet
Knee, Hip or Shoulder Pain
Degenerated or Bulging/Herniated/Protruding/Extruded Disc
Spinal Stenosis
Bone on Bone or Tears in Your Joints
Neuropathy Numbing/Tingling/Burning in Hands/Feet
What is your level of urgency to solve this problem?
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1-6 (not urgent)
7-10 (very urgent)
What are you trying to achieve by asking us for help?
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How Did You Hear About Us?
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Google
Family/Friend Referral
YouTube
Facebook
Other
If we are confident that we can help you to solve your problem and accept you as a patient...
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I have access to the resources to invest in my health
I do not have the resources to invest in my health
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