Name *

First Name

Last Name

Primary reason for wanting to speak to a specialist *

I'm not sure what to expect.

I'm not sure you can help me.

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'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 this way.

What's troubling you? *

Dizziness / Vertigo / Falling

Headaches / Migraines

Jaw Pain / Clicking (TMJ)

Neck Pain / Stiffness

Shoulder & Arm Pain / Stiffness

Wrist & Hand Pain / Stiffness or Carpal Tunnel

Low Back Pain / Stiffness

Sciatica / Shooting Nerve Pain

Hip Pain / Stiffness

Knee Pain & Stiffness

Foot & Heel Pain

Neuropathy

Chronic / Persistent Pain

Exercise / Weight Loss

Something else... (if so please describe in next section)

How long have you been dealing with your problem? *

Less than a week

1 - 4 weeks

1 - 2 months

3- 6 months

7 - 12 months

1 - 2 years

Longer than 2 Years

What is your MAIN concern that has you considering seeing us? *

The pain I'm having

Its not getting better / its getting worse

I cannot do the things that I need or want to do

I want to avoid painkillers or surgery

I'm afraid of losing my mobility and independence

What is your MAIN goal from having care? *

Improve pain

Improve stiffness & mobility

Improve function & activity

Move better

Sleep better

Phone *

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