Name
What service do you need?
*
Physical Therapy
Chiropractic Care
Functional Health
Personal Training
Nutrition Consultation
Health Coaching
Pelvic Floor Physical Therapy
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What type of session is preferred? (TH vs in person)
*
In-office session
Telehealth
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Pick your ideal day for an appointment
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Select Ideal Time (We're open 6am-6pm depending on the day) *
6:30AM
7AM
7:30AM
8AM
8:30AM
9AM
9:30AM
10AM
10:30AM
11AM
11:30AM
12PM
12:30PM
1PM
1:30PM
2PM
2:30PM
3PM
3:30PM
4PM
4:30PM
5PM
5:30PM
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How much time and attention do you prefer?
*
30 minutes (silver)
60 minutes (gold)
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Where does it hurt?
*
Back Pain
Knee Pain
Shoulder Pain
Neck Pain
Foot / Ankle Pain
Muscle injury from Sport / Exercise
Postnatal Back Pain
Headaches / Migraines
Hip Pain
A problem where you are not sure where it's coming from
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What does it stop you from doing?
*
What concerns you most?
*
Not knowing what's wrong
You want to avoid depending upon painkillers to ease pain
Losing mobility or independence due to chronic pain
The risk of facing dangerous surgery due to chronic pain
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How long have you suffered?
*
Haven't - this prevention (not cure)
A few days
1-2 weeks
About a month
> 3 months
Seems too long (years)
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Phone
*
Email
*
How did you hear about us?
*
Google
Yelp
Friend/Family Referral
Physician Referral
Event
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