Name
*
Email
*
Phone
*
Primary Reason for Wanting to Speak w/ a PT
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I'm not sure if Physical Therapy is right for me, and talking to a PT will help me decide
I'd like to know the Root Cause of my pain or issue if you can help me fix it
I'm in a lot of pain and I'd like to know if you can help me
I have issues with my balance and mobility and want to know if Physical Therapy can help me
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Where Does It Hurt (or other issue)?
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Not sure where it's coming from
Lower Back Pain
Sport or Work-Specific Injury
Sciatica/Nerve Pain
Knee Pain
Shoulder Pain (Rotator Cuff)
Neck Pain and/or Headaches
Pre or Post-Surgery Issue
Foot/Ankle Pain
Balance & Fall Prevention
Sport or Work-specific Injury
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How Long Have You Dealt With This Issue?
*
A few days
1-2 weeks
2-4 weeks
1-3 months
3-6 months
6 months - 1 year
Too long! (more than 1 year)
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List is empty.
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