First Name *
Last Name *

Email *

Phone *

Time Zone *

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How were you referred to our office?

Is your case neck-related? *

YesNo

Current diagnoses or primary medical concern: *

What are the primary functional goals you are trying to achieve? *

For example, resume marathon training, return to college, walk my children to/from school, be able to perform my manual labor job full-time, etc… Functional goals would not be “to feel NORMAL” or “to feel BETTER” as these feelings differ greatly for each person who is suffering from a chronic condition. You could also list some objective ways by which you are measuring the success of the treatments you have already received or are looking to receive.

Schedule an appointment at Caring Medical Florida *

as soon as possiblewithin a couple weekswithin 1-2 monthsI am not looking to schedule an appointment at Caring Medical Florida