Arrange Your Free (15 Minutes) Telephone Consultation With a Doctor of Physical Therapy
So That We Can Serve Your SPECIFIC Needs, Please Fill Out This Quick Form And Show Us EXACTLY How You Want Us To Help YOU... The more we know about you, the better we can help you. Please check the statement that BEST matches you below.*
I'm in lots of pain and want some tips and advice I can start using right away
I would love to know what's wrong and how long it will take to ease
I'm not sure if Physical Therapy is right for me, and talking to a Physical Therapist first would help me decide
Where Does it Hurt?*
Back
Lower Back
Knee
Leg
Neck/Shoulder
Foot/Ankle
Hip
Pelvic Region
Arm/Wrist/Elbow
Head/Jaw
Headaches/Migraines
Muscle Injury from Sport/Exercise
Not Sure Where it's coming from
If Other Please Describe Here: (Optional)
What Does it Stop You from doing?*
What Concerns You The Most That Makes You Want To Consider Physical Therapy?
The pain you're experiencing
Not knowing what's wrong
Want to avoid pain killers & medications
Fear of not being able to stay active
The risk of needing dangerous surgery
Concern at no sign of improvement
How Long Have You Suffered or Worried? *
Haven't- This is prevention (not cure)
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough (4+ months)
Seems Like Too Long (Years)
Check Any Boxes Below That You Value Most When Making Your Decision to Choose a Physical Therapist?
Natural Treatments--Don't want medication or pain killers
Hands-on Care (Manual Therapy, Massage, etc.)
One on One Care
Home Exercises and Self Treatment to Speed Up Recovery
Ability to Limit the Chance the Pain will return anytime soon.
On a Scale of 1 to 10, How Motivated are You to Take Care of your Problem Right NOW?
1 = Not Motivated At All
2- 4 = Low motivation
5 = Somewhat Motivated
6 = I'm slightly motivated but I can live through it.
7 = Motivated, but I have some doubts
8 = Definitely Motivated
9 = Very Committed
10 = Absolutely committed NOW. I'll do whatever it takes!
Main Goal of Using Our Specialist Service
Ease Pain
Ease Stiffness
Get Active
Stay Active
Avoid Painkillers Dependency
Find Out What's Wrong
Stay Healthy and Get Fixed BEFORE Pain Gets Worse
Best Time For a Call Back
During The Day
After 5 pm
Anytime
Full Name*
Phone*
Email*
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