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Request Appointment (2025)

Company

This field is for validation purposes and should be left unchanged.

First Name(Required)

Last Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Phone(Required)

Address(Required)

I Am A...(Required)

Preferred Appointment Day?(Required)

Preferred Appointment Time?(Required)

Reason for Visit (check all that apply)(Required)

Sports Medicine

Athletic Recovery

Primary Care

Chiropractic Care

Foot and Ankle Care

Physical Therapy

Acupuncture

Flu Shot

Spine & Orthopedic Care

Pain Management - PRP, joint, epidural Injections

Regenerative Medicine, and Stem Cell Therapy , BMAC, Shockwave Therapy (EPAT), Peptides, NAD+

Neurology / Nerve Testing

Hormone Replacement Therapy (HRT), Testosterone, Menopause-related care & Peptides

IV Vitamin Therapy

Weight Loss & Wellness

Annual Adult Physicals

Athlete Readiness Exams & Preventive Health Physicals for Adults

Allergy & Immunology (environment and food testing)

Rheumatology / Autoimmune Care

Imaging & Diagnostics (X-ray / Diagnostic Imaging, EMG)

Laboratory Services & Blood Work (Preventive labs, Hormone panels, Autoimmune & inflammatory markers)

Occupational Therapy (OT)

Pre-Op / Post-Op Care Coordination

Medical Weight Loss (GLP-1s, Semaglutide, etc.)

Workers’ Compensation Injury

Personal Injury / Accident

Slip and Fall

Motor Vehicle Accident

Workers’ compensation and personal injury visits require documentation before scheduling. Please provide the claim number, adjuster information, and MRI report related to the injury.

Date of injury or accident(Required)

MM slash DD slash YYYY

Type of accident(Required)

MRI report upload(Required)

Max. file size: 64 MB.

Accident report or claim document upload(Required)

Max. file size: 64 MB.

I confirm the information above relates to my injury claim.(Required)

Yes

Are you currently experiencing ANY of the following? (Check all that apply)(Required)

Neck Pain

Low Back Pain

Mid Back Pain

Hip Pain

Knee Pain

Shoulder Pain

Elbow Pain

Wrist/Hand Pain

Foot/Ankle Pain

Sciatica / Radiating Pain

Muscle Spasms or Tightness

Weakness, Numbness, or Tingling

Headaches or Migraines

Joint Stiffness or Arthritis

Arm

Leg

Pelvic/SI Joint

I am not experiencing any pain or discomfort

Vein Health & Circulation Screening

Are you experiencing ANY of the following leg symptoms? (Check all that apply)(Required)

Leg heaviness or fatigue (especially by the end of the day)

Aching, throbbing, or cramping in the legs

Swelling in the ankles, feet, or calves

Varicose veins (bulging, twisted veins)

Spider veins

Burning, itching, or tingling in the legs

Restless legs or leg cramps at night

Tightness, pressure, or numbness in the legs

Skin discoloration or darkening near the ankles

Skin thickening or dryness in the lower legs

Slow-healing wounds or sores on the legs or ankles

I am not experiencing leg symptoms

When do your leg symptoms feel worse?(Required)

After long periods of standing

After sitting for long periods

At the end of the day

At night

During or after exercise

Symptoms improve when I elevate my legs

Not applicable

Do any of the following apply to you? (Check all that apply)(Required)

Family history of varicose veins or vein disease

Job requires long hours of standing or sitting

History of pregnancy

Prior leg injury, surgery, or blood clot

Overweight or recent weight gain

History of swelling in the legs

I have been told I have circulation or vein issues

None of the above

How much do your leg symptoms affect your daily life?(Required)

Mild – noticeable but manageable

Moderate – uncomfortable and distracting

Severe – limits activity, sleep, or work

Not applicable

Do any of these apply to you? (Check all that apply)(Required)

Chronic joint pain lasting more than 3 weeks

Pain after a recent injury

Limited range of motion

Swelling or inflammation

Recurrent sprains or weakness

History of arthritis, tendonitis, or bursitis

Chronic fatigue

Unexplained weight gain

Hormonal or menopausal symptoms

Recurrent headaches or migraines

Autoimmune symptoms (rashes, elevated labs, etc.)

Prior epidurals, injections, or surgeries

None of the above

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Where is your PRIMARY area of pain?

Neck

Back

Mid Back

Hip

Knee

Shoulder

Foot/Ankle

Leg

Arm

Hand/Wrist

Head

Pelvic/SI Joint

Elbow

I have multiple areas

Not applicable

How severe is your pain today?(Required)

0 = no pain, 10 = worst imaginable

Tell us more about your pain or symptoms(Required)

– When did it start? – What makes it better or worse? – Have you tried treatment already? – Any numbness, tingling, weakness, or instability?

How did you hear about us?(Required)

What is your Friend/Family name?(Required)

What Social Media did you hear about us?(Required)

If you have changed your insurance, employer, plan, pharmacy, or received a new driver’s license, please upload your updated documents. Providing updated information helps prevent delays in eligibility verification and prescription processing.

Insurance Name

Group #

Member ID

Rx Card Number

Driver’s License