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    As it appears on your ID, Insurance card or medical record

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    Please enter the best available phone number to reach you.

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    Please upload a picture of your insurance card OR
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    (If different from primary)

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    Pain Assessment

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    YesNo

    Current Ailments

    HeadNeckShoulder (Right)Shoulder (Left)Elbow (Right)Elbow (Left)Wrist (Right)Wrist (Left)Hand (Right)Hand (Left)Hip (Right)Hip (Left)Knee (Right)Knee (Left)Ankle (Right)Ankle (Left)Foot (Right)Foot (Left)Leg (Right)Leg (Left)Back (Upper)Back (Mid)Back (Lower)

    PainLoss of Use/MovementAltered Sensation

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