Free Injury Screening

Fill in as many of the fields as possible.  Someone will contact you shortly. 

Thank you.

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What part of your body has been bothering you? 

How long has it been bothering you?   --Make a Selection--How long botheringAt least 6 monthsAt least 2 yearsI cannot remember life without it 

Have you tried physical therapy in the past?  --Make a Selection--Yes with great resultsYes with limited resultsYes with no resultsNo I have not 

Do you have insurance?   --Make a Selection--Yes and I am coveredYes but I am not sure if I am coveredYes but I am not coveredNo I do not

What time of day is best for your first appointment?  --Make a Selection--7 am to 10 am10 am to 12 pm12 pm to 2 pm2 pm to 5 pm

Name:        
Email:         
Telephone:   
City:          

Please contact me as soon as possible?   

         

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