First Name
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Last Name
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How Did You Hear About Us?
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Primary Reason For Wanting To Speak With A Specialist
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I'm in lots of pain and want some tips and advice I can start using right away
I would love to know what's wrong and how long it will take to ease
I'm not sure if Physical Therapy is right for me and talking to a specialist first would help me decide
How Long Have Your 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)
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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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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Best Time For A Call Back
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Through The Day
After 5pm
Anytime
Phone
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Email
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