First Name
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Last Name
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How Did You Hear About Us?
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Which Service do you need?
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One on One Physical Therapy
Mobility Work
Dry Needling
Custom Foot Orthotics
Pick your ideal day for an appointment
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Pick your ideal day for an appointment
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Indicate Ideal Time (We're open 8:00am - 7pm)
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Indicate Ideal Time (We're open 8:00am - 7pm)
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
5:00pm
6:00pm
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How Much Time and Attention Do You Prefer?
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How Much Time and Attention Do You Prefer?
30 minutes
60 minutes
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Where Is Your Pain or Stiffness?
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Where Is Your Pain or Stiffness?
Back
Neck
Shoulder
Arm
Hip
Knee
Foot/Ankle
Muscle Injury from Sport/Exercise
Not sure where it's coming from
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What does it STOP you from doing?
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What Is Concerning You Most That Makes You Want To Consider Physical Therapy
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What Is Concerning You Most That Makes You Want To Consider Physical Therapy
A dependence on pain killers for relief
Losing your mobility and independence
Knowing what's wrong
Having to result to costly surgery
Not being able to exercise the way you want
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How Long Have You Suffered Or Worried?
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Haven't - this is prevention not cure
1-2 weeks
2-4 weeks
1-3 months
Long enough
Seems like too long (years)
Your Main Goal That You Would Like To Achieve With Us
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Your Main Goal That You Would Like To Achieve With Us
Ease pain
Ease stiffness
Get mobile
Increase activity
Avoid a dependence on painkillers
Improve flexibility
Improve posture
Find out what's wrong
Get healthy and fix the problem BEFORE the pain gets worse
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Phone
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Email
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