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First Name
*
Last Name
*
Phone
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Email
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Which Service Do you Need? (Select all that apply)
*
Physical Therapy
Deep Tissue Laser
Dry Needling
Blood Flow Restriction
Not Sure
Occupational therapy
Where Does It Hurt? (Select all that apply)
*
Low Back
Neck
Knee
Ankle/Foot
Post Surgical
Muscle injury from ports or exercise
Not sure where it is coming from
Shoulder
Balance
What does it stop you from doing?
Your Main Concern: (Select all that apply)
*
Dependency on painkillers
Fear of losing mobility
The risk of needing dangerous surgery
Independence
Not Knowing What is Wrong
How long have you suffered or worried?
*
A few days
1-2 weeks
2-4 weeks
1-3 months
Long enough
Too Long (years)
The main goal you would like us to help achieve for you
*
Ease Pain/Stiffness
Get/Stay Active
Avoid dependency on painkillers
Find out what is wrong
Stay healthy and get fixed BEFORE pain gets worse
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