First Name
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Last Name
What are dealing with?
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Urinary Leakage
Pain
Something's not working right
Pregnancy concern
Postpartum concern
Post-surgery recovery concern
Bowel problem (constipation, fecal leakage, etc)
What does it stop or prevent you from doing?
What Is Your Main Concern That Has You Considering Physical Therapy?
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What I’ve tried before hasn’t helped
I'm out of options
Not knowing what's wrong
No signs of improvement yet
Other
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What is the main thing you would like us to help you achieve? (choose one)
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Help in deciding my next step for recovery
Learn more what it's like to work with us
Provide information and resources
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Insurance Coverage
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Blue Cross Blue Shield
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Medicare Part B
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How important is using your insurance in solving this problem?
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Essential: If I can't use my insurance I'm not interested
Important but not a game changer
Doesn't Matter, I'll do anything to get better!
Does not apply to me
Best day for an appointment:
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Best time for an appointment:
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