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
Please answer the following to ensure this treatment is appropriate for you:
I am currently pregnant
*
Yes
No
I have a bleeding disorder or take blood thinners (e.g., warfarin, Eliquis)
*
Yes
No
I have a pacemaker or implanted electrical device
*
Yes
No
I have active cancer in the area to be treated
*
Yes
No
I have an open wound, infection, or skin condition over the treatment site
*
Yes
No
I have had a cortisone injection in the treatment area within the past 6 weeks
*
Yes
No
Treatment & Policy Acknowledgments
I understand that Shockwave Therapy is not covered by insurance and is a self-pay service
*
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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