Shockwave Therapy Candidate Form
Let us know how we can help you!
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
What condition are you hoping to treat with Shockwave Therapy?
*
Please Select
Plantar Fasciitis
Frozen Shoulder
Tennis Elbow / Golfer’s Elbow
Achilles Tendinopathy
Rotator Cuff Pain
Hip Bursitis
Trigger Points
Chronic Neck & Back Pain
TMJ Disorders
Other / Not Listed
Treatment & Policy Acknowledgments
I’ve reviewed the contraindications listed on the request page, and none of them apply to me.
*
Yes
No
I understand shockwave therapy is typically not covered by health insurance. Costs, and any auto insurance (PIP) coverage, will be reviewed before treatment.
*
Yes
No
I understand this is a request for a preferred appointment time and that my booking is not confirmed until contacted by a member of the office team
*
Yes
No
What date and time work best for you?
Submit
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