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Primary reason you want to speak to a PT:
Where is your pain or stiffness?
What does it stop or limit you from doing?
How long have you suffered or worried?
Best time for a zoom consultation:
What concerns you most about your pain/dysfunction?
Please select all that applies to you:
Pain with sexual intercourse
Pelvic and/or abdominal pain
Low back pain
Urinary incontinence/leakage
Urinary urgency and/or frequency
Prolapse
Pre/postnatal rehab
Diastasis Recti
Other*
If you selected "other" in the previous prompt OR if you are requesting more information about your condition, please explain*
First name
Best phone number
Last name
Email
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