1) In your own words and to the best of your ability describe your chronic pain (i.e. muscles/joints affected, impact on your life etc). (Required)

2) What previous interventions have you tried/who have you worked with to solve your chronic pain (i.e. physio/physical therapy, osteopathy, drugs etc) ? Leave empty if this is not applicable to you.

3) Has a dentist diagnosed any issues regarding your teeth and/or an optometrist diagnosed any issues regarding your eyes (i..e braces, molars, glasses, vision type etc) ? Leave empty if this is not applicable to you.

4) Is there anything other information you feel as though I should know before getting back to you (i.e. diagnosis of a specific problem, lifestyle issues etc) ? Leave empty if this is not applicable to you.

Phone Number (Required)

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