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(704) 905-1333
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Tell us about your condition, care history, and contact details to get started.
1
Patient Details
2
Payment Information
First Name
*
Last Name
*
Preferred Name
Date of Birth
*
What Will We Be Working On?
*
How severe is the pain level?
Select...
0/10 (No Pain)
1/10
2/10
3/10
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6/10
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How long has this effected you?
Have you seen a medical provider?
*
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Who Is Your Doctor?
Doctor’s Phone?
What previous treatment have you had?
*
What is this problem stopping you from doing today?
Address
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Phone Number
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Email Address
*
How did you hear about us?
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Preferred Clinic Location
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Mint Hill Office
Mobile Therapy
How will you be paying for services?
*
Insurance (40-60 min)
Paying Privately (40-60 min)
Free Assessment (20 min)
Insurance Name
Insurance Member ID
Insurance Group Number
Provider Phone Line (Back of Card)
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7900 Matthews Mint Hill Rd, Suite 300
Mint Hill, NC 28227
(704) 905-1333
(704) 565-4285
[email protected]
Mon – Fri 8.00am – 7:00pm
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Contact Info
Phone
1-2345-6789-33
Drop us a line
[email protected]
Address
1810 Kings Way, New York
