First Name *

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What are you hoping to get relief from? (Select all that apply) *

How long have you been dealing with this issue? *

Insurance is not necessary, but if you have it, we will do a complimentary benefits check on your initial visit. Do you currently have any of the following insurance? *

Required Confirmations

By checking this box, I confirm that I:

I'm ready to book an appointment
Understand that this treatment is not covered by insurance
Understand that the initial visit cost is $49.

I understand and agree to all of the above.

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