Please tell us...
Please Enter Your First Name
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Primary Reason For Wanting To Speak With A Specialist
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I've never had this kind of physical therapy and am not sure what to expect
I would like to see if we are a good fit first
I'm not sure if physical therapy can help me/ I've tried this before and it didn't work
I have some questions and concerns I'd like to talk about before committing to an appointment
I am a caretaker or family member of someone who needs this kind of physical therapy
Other
What do you want to talk about?
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Please select one
I'm having pain
I'm leaking
My problem is interfering with my workouts/exercise
My problem is interfering with my relationships
I want to prepare my body during pregnancy
I'm having trouble recovering after childbirth
Other
What Does Your Problem Keep You From Doing?
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What's Your Main Concern That Has You Considering Physical Therapy?
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Please select one
The pain I have
This is
embarrassing
This is affecting my intimate relationships
This is affecting my exercise and/or activities I enjoy
Worry about not knowing what's wrong
Want to avoid surgery or drugs
What I've tried before hasn't helped
Other/I'd rather not say
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 would be the one thing you would like us to achieve for you?
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Ease pain
Stop leakage
Stay active or involved in exercise
Avoid surgery or medication
Find out what's wrong
Get things to work right again
Help with recovery after childbirth
Prepare my body for labor and delivery
Provide resources
What Is Your Insurance Coverage?
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Blue Cross Blue Shield
Medicare B (Traditional Medicare)
Medicare Advantage
Self Pay
Other
How Important Is Is That You Use Your Insurance to Solve This Problem?
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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 we can arrange this Consultation Visit for you, please tell 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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