First Name
*
Last Name
*
Reason for Wanting a DV
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I'm new to this type of therapy and not sure what to expect
I was let down by another therapist in the past and would like to see how good you are before I commit
I'm NOT sure if you 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
It's just easier for me to do it this way
What Are You Struggling With?
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Lower Back Issues
Stenosis
Back
Hip
Knee
Ankle/Foot
Elbow
Wrist
Hand
Knee
Hip
Shoulder/Neck
Foot/Ankle
Muscle Injury from Sport/Exercise
Postnatal Back Pain
Headaches/Migraines
TMJ
Gait Dysfunction
Arthritis Pain
Post Surgical Pain
Not Sure
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What Does It Stop You From Doing?
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What Concerns You Most?
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Not Knowing What's Wrong
Dependency Upon Painkillers
Fear Of Losing Mobility Or Independence
Risk Of Facing Dangerous Surgery and/or Injections
Other Concern (Not Listed)
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How Long Have You Suffered or Worried?
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Haven't - This is prevention (not cure)
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough
Seems Like Too Long (Years)
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What Is the Main Goal You Would Like Us to Help You Achieve?
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Ease Pain
Ease Stiffness/Tightness
Get Active
Stay Active
Avoid Painkillers/Injections/Surgery
Find Out What's Wrong
Stay Healthy & Get Fixed BEFORE Pain Gets Worse
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Please tell us where to contact you with the outcome of the Free Discovery Visit application:
Phone
*
Email
*