801-987-0335 SCHUDULE PHONE CONSULT
Home
Questions ? Phone Consult
Men's E.D. Care
Learn about E.D. Wave Care
Men's Erectile Dysfunction Score
Muscle & Joint Shock Wave
Heel Pain
>
Plantar Fasciitis
Achilles Tendonitis
Knee Pain
Hip Pain
Low Back Pain
Neck Pain
Shoulder Pain
Elbow Pain
Ankle Pain
Fill out form to best diagnosis your Ankle Pain
Health Insurance will not cover Muscle & Joint Wave Care.
Patients will pay out of pocket for Wave Care, by using Health Savings/ FSA,
debt card, Cash and credit card.
*
Indicates required field
Do you have a budget for Wellness Care
*
Yes
No
Name
*
First
Last
Cell Phone Number
*
Text message
How do you want to be contacted?
*
Text Message
Call
Have you had Ankle Pain that
Weakens
you when you walk or run?
Due to ankle twisting and instability you can't walk or play due to pain
*
Yes
No
I don't recall
Do you have any ankle pain that keeps you from activity or work?
Pain in the ankle hurts worst during activity
*
Yes
No
I don't know
How would you rate your Ankle pain?
How would you rate your pain?
*
1-3
3-4
5-6
7-8
8-9
10
Prefer not to say
Where do you feel Ankle Pain?
Outside of Ankle
Inside of Ankle
Inside of the Ankle
*
Yes
No
Not Sure
Outside of Ankle
*
Yes
No
Not Sure
Submit
Home
Questions ? Phone Consult
Men's E.D. Care
Learn about E.D. Wave Care
Men's Erectile Dysfunction Score
Muscle & Joint Shock Wave
Heel Pain
>
Plantar Fasciitis
Achilles Tendonitis
Knee Pain
Hip Pain
Low Back Pain
Neck Pain
Shoulder Pain
Elbow Pain
Ankle Pain