Full Name
*
Phone
*
What is going wrong and how did it happen?
*
Check the box if you have had any of the following medical conditions:
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Diabetes
Rheumatic fever
Heart Murmur
Circulatory problems
Lung disease
Osteoporosis
Malignancy
Liver disease
Weight change
Migraine/headaches
Arthritis
Heart disease / pacemaker
Varicose veins
Epilepsy / seizures
Broken bones (fractures)
Kidney disease
Neurological problems
Stroke
Metal implants
Pregnancy
Blackouts
High blood pressure
Others (explain below)
Please briefly describe your current health and lifestyle.
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Email
*
What is the main goal you would like us to help achieve for you?
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Ease pain
Ease stiffness
Get active
Stay active
Avoid painkiller dependency
Find out what is wrong
Stay healthy and get it fixed BEFORE it gets worse
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
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