Please Enter Your First Name
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Please Enter Your Kid's Name (if requesting on behalf of a child)
Primary Reason For Wanting To Speak With A Specialist
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I'm new to physical therapy and am not sure what to expect
I was let down by another physical therapist in the past and would like to see how good you are before I commit
I'm not sure if physical therapy 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
Other
Where Does It Hurt?
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Please select one
Back
Knee
Shoulder/Neck
Sports or Exercise Injury
Foot/Ankle
Wrist/Hand
Elbow
Not Sure Where It's Coming From
What Does It STOP 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 you are experiencing
Fear of not being able to keep active/involved in sporting activity
Worry about not knowing what's wrong
Want to avoid painkillers
Concern at no signs of improvement
Future ill health (and wanting to prevent it)
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
Ease stiffness
Stay active or involved in sporting activity
Avoid painkiller dependency
Find out what's wrong
Stay healthy and get better before the pain gets worse
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What are you most interested in? Choose all that apply:
Therapy and rehabilitation of injury
Return to fitness
Longevity/staying active
Best Phone Number
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Best E-mail
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