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Please provide your information so we can better serve your therapy needs. All information will be kept confidential and will not be shared with outside parties.
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Email
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First, Last Name
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Birthdate
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Email
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Social Security Number (Of client seeking services)
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Primary Insurance (Subscriber Name, ID #, Group #)
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Address
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Phone number
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Are you experiencing any of the following:
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Pain
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Dizziness
Generalized weakness
Falls/Balance Issues
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Tell us a little more of what you're experiencing.
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