Physical Therapy Clinic | CA | ReVITALize Rehab Club
Schedule Appointment
Inquire About Cost And Availability
Inquire About The Cost And Availability
Please fill out this form so we can understand how to serve you best.
Step 1 of 3 – About You
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Please Enter Your First Name
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First
Pick Your Ideal Day For An Appointment
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Please Select One
Monday
Tuesday
Wednesday
Thursday
Saturday
How Much Time And Attention Do You Prefer?
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Please Select One
30 Minutes (Silver)
60 Minutes (Gold)
Where Does It Hurt?
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Please Select One
Lower Back
Knee
Shoulder
Neck / Headache
Foot/Ankle
Elbow / Wrist / Hand
Muscle Injury from Sport/Exercise
Nerve Pain
Chronic Health
Not Sure Where It's Coming From
What Does It STOP You From Doing?
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Your Main Concern
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Please Select One
The Pain You Are Experiencing
Worry Over Not Knowing What Is Wrong
Concern at No Signs of Improvement
Want to Avoid Painkillers
Fear of Not Being Able to Be Active
How Long Have You Suffered Or Worried?
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A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough
Too Long (Years)
The Main Goal You Would Like Us To Help Achieve For You
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Please Select One
Ease Pain
Ease Stiffness
Get Active
Stay Active
Avoid Painkillers Dependency
Find Out What's Wrong
Stay Health and Get Fixed BEFORE Pain Gets Worse
What do you value the most when making a decision in fixing your problem in the next few weeks?
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Please Select One
Someone that listens
Honesty and Transparency
Time Availability
Someone that has seen my condition before and can get to the root cause
Money
Being comprehensive so I get better soon
Not being rushed
Phone Number
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