First Name *

Last Name *

Phone *

Email *

Where is the injury? *

Knees

Shoulder

Neck

Hip

Ankle

Leg

Back

Arm/Wrist

Concussion

On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain? *

1

2

3

4

5

6

7

8

9

10

Describe your Pain/Discomfort.

How long ago did you sustain this injury? *

0-3 Months

3-12 Months

1-3 Years

Over 3 Years

What have you tried in the past that has not corrected your problem? *

Is there anything else you’d like to share with us regarding your goals?

We currently do not work with any insurance providers, in doing so we are not limited by insurance's standard care and can find the root cause of your problems to help you truly heal. Do you wish to continue?

Yes

No

Possibly, if I had more information.

I understand Secoya Health has a 24 hour rescheduling policy. If I cancel within 24 hours the IV deposit will not be returned. *

I Acknowledge

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