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First name
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Last name
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Email
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Phone number
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Congratulations on taking the first step!
Let's see if we can help.
What are your current health goals?
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What are you (possibly) having trouble figuring out on your own?
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How long has this been an issue and why is it important for you to solve this issue now?
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What do you currently do for work and what are the physical job demands?
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What do you like to do for fun?
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How much have you invested in your health to solve your current problem?
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$0-$999
$1,000-$2,999
$3,000-$5,999
$6,000+
Click on all forms of treatments you've tried in the past.
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Injections
Surgery
Physical Therapy
Chiropractor
Acupuncture
Massage
Personal Training
Psychotherapy
Heat/Cold Pack
Medication
Pain Creams
Electrical Stimulation
Braces
None
Other
Where did you find out about FlexwithDoctorJay?
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Facebook
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Referral
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