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Please tell us...
Interested to Work With Us In Person?
One-on-one physical therapy sessions in our Olathe, Kansas clinic
Please Enter Your First Name
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What are you dealing with?
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Please select one
Pain
Leakage
Pregnancy concern
Birth Healing concern
Somethings not working right
Want to recover better after surgery
Other
What Does It Limit or Stop You From Doing?
Your Main Concern
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Please select one
The pain I have
This is embarrassing
How this is affecting my activity level
Worry about not knowing what's wrong
This is affecting my sex life
Want to avoid surgery or medications
No signs of improvement yet
Fear that my condition may get worse
Other
How Long Have You Suffered Or Worried?
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A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough
Too Long (Years)
What do you value most when making your decision to choose a Physical Therapist? (check all that apply)
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Natural Treatments
Hands on care (example: massage, manual therapy, etc.)
One-on-one care
Home Exercises To Speed Up Your Recovery
Trust and Confidentiality
Other
The Main Goal You Would Like Us To Help Achieve For You
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Please select one
Ease pain
Stop leakage
Stay active or involved in exercise
Avoid surgery or medication
Find out what's wrong
Help with recovery after childbirth
Prepare my body for labor and delivery
Other
What Is Your Insurance Coverage?
Blue Cross Blue Shield
Self-Pay
Medicare B (Traditional Medicare)
Medicare Advantage
Other
How Important Is Is That You Use Your Insurance to Solve This Problem?
Essential: if I can't use my insurance I'm not interested
It's important but not a game-changer
Doesn't matter, I'll do anything to get better!
Does not apply to me
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So that we can contact you about this, please give us:
Best Phone Number
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Best E-mail
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Consent to Contact
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I consent to being contacted by SMS, phone, or email for the purpose of responding to my inquiry.
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