Physiomed Community App + Free Program Application Form

1
Your Name + Clinic Connection * This field is required.Please insert your name + the name of the main practitioner you work with/the name of the patient who invited you.
First Name
Last Name
Main Practitioner / Patient Inviting You
2
What is your best E-mail?* This field is required.This will be used to send you your unique link to join the free program. (Arrives in 1-5 Mins)
example@example.com
3
Which Clinic Do You Attend? / Which Clinic is Nearest to You?* This field is required.If you are being invited by a patient, which clinic would you go if you were to get an in-person assessment?
Please Select
Please Select
Airport
Alliston
Barrie North
Bellamy
Bell's Corner
Bramalea
Burlington
Cambridge
Danforth
Dixie
Donwsview
Elgin Mills
Erin Mills
Fletcher's Creek
Hamilton
Humber
Kennedy
Lakeshore
Leaside
Maple
Milton (Bronte)
Milton (Main)
MMSK
Nobleton
Oakville
Orangeville
Rogers Road
Sherway
Southdale
St Clair
Tenth Line
Thornhill (Pavillion)
Thickson (Whitby)
Vancouver
Vaughan (Roytec)
Waterloo
Yonge-Bloor
Yorkdale
Clinics Listed A-Z Alphabetically.
4
Your Phone Number* This field is required.Necessary for proper text-reminders.
Please enter a valid phone number.
5
What are your dream health, fitness & pain recovery goals? Please describe your goals for the next 3 months, 6 months & 2 years.* This field is required.Please be specific as this helps us give you additional resources in order to help you further; ie: please don't just state that you want to "be healthy".
6
Anything else we should know about your situation?* This field is required.So our team can help you best.
7
Do you agree to schedule & attend both your program calls within 24hrs of submitting this form? * This field is required.(The call booking link will redirect after submitting this form + will be emailed directly to you after submission. You will have 72 hours to schedule these calls otherwise accounts in the program app get auto-removed)
Yes. I Understand these calls are to help ME get amazing health results. I will schedule times I can attend with no distractions, and attend even if I don't use the app's material; simply out of courtesy to the professionals here helping me personally for free.
Yes ➕ I'd love earliest seating for my Blueprint call in order to get my custom documents & 1 on 1 help from an expert as fast as possible! ⭐
Yes ➕ I’m interested in further in-person treatment, training, testing & health hacking resources at Physiomed Clinics
Yes ➕ My goals are currently my top priority. I request to be notified when openings arise in Physiomed's paid health programs that guarantee that I will achieve specific health results. So that I can consider applying 🎯
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