PACE Physical Therapy -

Ask About Availability And Cost

So that we can meet your SPECIFIC needs, please fill out this 35 second form and let us know EXACTLY how you want us to help YOU. The more we know about you, the better we can help you… P.S. Your information is 100% safe with us. We will not share it with anyone!

First Name*

Last Name*

Which Service(s) Do You Need?*

In Person Or Remote?*

Where Do You Hurt/Have Pain?*

What Does It Stop You From Doing?*

Your Main Concern*

The Pain You Are Experiencing

Fear Of Not Being Able To Remain Active Or Playing Your Sport

Worry About Not Knowing What Is Going On

Want To Avoid Painkillers

Concerns At No Signs Of Improvement

Future Ill Health (And Wanting To Prevent It)

How Long Have You Suffered Or Worried?*

A Few Days

1-2 Weeks

2-4 Weeks

1-3 Months

Long Enough

Too Long (Years)

What Do You Value Most When Making Your Decision To Choose A Physical Therapist? (Check All That Apply)*

Natural Care

Hands-On Care (Massage, Manual Treatment, Etc)

One-On-One Care

Home Exercises To Speed Up Recovery

Being Educated On What Is Occurring

What Is The Main Goal You Would Like Us To Help You Achieve?*

Ease Pain

Ease Stiffness

Understand Your Injury/Pain

Stay Active Or Involved In Your Sport

Stay Healthy

Avoid Pain Medication

How Did You Hear About Us?*

What Is The Best Time Of Day To Contact You? (Central Standard Time)*

Morning 8-11 am

Lunch 11-1 pm

Late Afternoon 3-5 pm

Evening 5-7 pm

Phone*

Email*