Please tell us...
Please enter your first name
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Primary reason for wanting to speak to a specialist
I'm not sure what to expect
I've been let down by other healthcare providers in the past, and I'd like to see how you're different before I commit
I'm not sure that you can even help me
I'd like to get a feel for what you can do to help me BEFORE I commit to a full appointment
It's just easier for me doing it this way
Where do you have the MOST pain?
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Please select one
back
hip
neck
TMJ
headache
knee
foot
shoulder
elbow
wrist & hand
whole body
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What do your symptoms STOP you from doing?
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What is your MAIN concern that has you considering seeing us?
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Please select one
Not knowing what's wrong
Depending upon painkillers
Losing mobility or independence
The fear of needing surgery
How long has your problem been bothering you?
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A few days
1-2 weeks
2-4 weeks
1-3 months
4-6 months
7-11 months
1 - 2 years
3 - 5 years
6 - 10 years
More than 10 years
What is the main goal you would like us to help you achieve?
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Please select one
ease pain
improve stiffness
improve function
improve activity level
improve range of motion
sleep better
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So we can arrange this FREE Discovery Visit for you, please tell us:
Best Phone Number
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Best E-mail
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