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First Name *

Last Name *

Phone *

Email *

Date of birth

Are you local to the Reno/Tahoe area? *

Yes

No

If you were referred, who can we thank for sending you in?

If other, please specify.

How long have you been dealing with this issue? *

Weeks

Months

Years

What concerns you most about your condition? *

Not knowing what's wrong

Depending upon painkillers

Losing mobility or independence

The risk of facing dangerous surgery

Not being able to workout/stay active

Not being able to play sports

Are you committed to finding a long-term solution to your pain? *

Yes

No

What's the #1 thing you'd like to achieve!? *

What type of care are you looking for? *

A comprehensive rehabilitation plan customized specifically for my goals

Just a quick adjustment

Injury prevention

Performance

What is your biggest objection to committing to a plan of care? *

Time

Cost

I have none

Other

If other, please specify...

Are you willing to invest in yourself and your health? *

Yes

No

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