Book A Free Telephone Consultation

Name *

First Name

Last Name

Primary Reason For Requesting A Call * *

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 that you can even help me and talking to someone first would help me decide

I'm Having Trouble WIth *

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)

What is your MAIN concern that has you considering physical therapy? * *

The pain has gotten bad enough I need help

I want to keep it from getting worse

I cannot do the things I need or want to do

I want to avoid pain killers or surgery

I'm afraid of losing my independence and mobility

I've tried other treatments and they haven't worked

How long has your problem been bothering you? * *

Less Than A Week

1-4 Weeks

1-3 Months

4-6 Months

7-12 Months

1-2 Years

More than 2 Years

When would you perfer for us to try to reach you? * *

Before 8 AM

8 AM to Noon

Noon To 5 PM

After 5 PM

Doesn't Matter Call ASAP

Phone *

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