First Name
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Last Name
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Phone
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Email
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Age
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Height
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Weight
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Sex
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Type of Disease or Injury?
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How did this Injury occur
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MRI Yes-No
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If Yes how long ago?
MRI Timeline
Please describe your pain
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Pain Level 1 - 10
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5
6
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10
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Tried Stem Cells before
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Which Convention Treatments were used?
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Have you tried any other treatments?
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When are you looking to get treated
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Next 30 Days
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Just Looking for Information
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Can you travel Internationally for treatment?
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How did you hear about us?
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