So That We Can Serve Your SPECIFIC Needs, Please Fill Out This Form (it only takes 35 Seconds) And Show Us EXACTLY How You Want Us To Help YOU… The more we know about you, the better we can help you.
Where does it hurt?
Back
Low Back
Hip
Pelvic Region
Not Sure Where It's Coming From
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What Concerns You The Most That Makes You Want To Consider Physical Therapy?
The Pain You Are Experiencing
Not Knowing What's Wrong
Want to Avoid Pain Killers & Medications
Fear of Not Being Able to Stay Active
The Risk of Needing Dangerous Surgery
Concerns at No Sign of Improvement
Fear of Missing Out on Activities with the Kids
Afraid of Always Having to Deal with Leakage
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How Long Have You Suffered or Worried?
Haven't - This is Prevention (Not Cure)
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough (4+ Months)
Seems Like Too Long (Years)
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Please Choose Your Ideal Day(s) For An Appointment
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Please Indicate Your Ideal Times
6am
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
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