new client inquiry Thank you for taking the time to fill this out. Your responses will help us provide the best possible care. Name * First Name Last Name Email * Phone * (###) ### #### Preferred Method of Contact: * Phone Call Text Message Email Best Times to Reach You: * Date of Birth * MM DD YYYY Please provide a brief description of your condition: * On a scale of 1-10, with 10 being severe, how would you rate the pain you're feeling? * 1 - mild 2 3 4 5 6 7 8 9 10 - severe How long have you been dealing with this condition? * Less than 1 month 1-6 months 6-12 months Over 1 year Have you seen a physician for this condition? * Yes No Have you seen other healthcare providers for this condition? * If yes, please list the providers you've seen: (e.g., Chiropractic, Acupuncture, Physical Therapy, Massage Therapy) Have you had any imaging of your condition? * If yes, please list the type of imaging and approximate date: (e.g., X-Ray, MRI, CT scan) What services are you interested in? Integrative Performance & Aging Therapy Cold Laser therapy Pulsed Electro Magnetic Field Therapy Frequency Specific Microcurrent Neux pro neuromuscular stimulation virutal consultations home program injury recovery personal training Acknowledgment of Payment Policy * I understand that the Human Performance Center does not process insurance claims. All services are offered on a cash, credit card, or check basis, and payment is due at the time of service. Thank you! We have received your inquiry. Please allow up to 72 hours for us to contact you.Do you follow us on Social Media?Connect with us on Facebook and Instagram
