Appointment Request
Patient's Full Name
Please enter your full name in order for us to process your appointment request
Mobile Number
Birthday
Services
Please select
Scoliosis Comprehensive Program
Neuro Tecar Therapy Upper Extremity (NEURO/PEDIA Service)
Neuro Intensive Therapy Upper and/or Lower Extremity (NEURO/PEDIA Service)
Neuro Basic Therapy Upper and/or Lower Extremity (NEURO/PEDIA Service)
Dry Needling Myotherapy (Musculoskeletal Service)
Laser Shockwave Therapy (Musculoskeletal Service)
Shockwave Myotherapy (Musculoskeletal Service)
Laser Myotherapy (Musculoskeletal Service)
Tele-consultation with Rehab Doctor
Assessment
Pain Basic Therapy (Musculoskeletal Services)
Electro Needling Myotherapy (Musculoskeletal Services)
Tecar Myotherapy (Musculoskeletal Services)
Myotherapy (Musculoskeletal Services)
Service
Preferred Date
Preferred Time
Is this your first visit?
Preferred Doctor
Reason for Appointment/Chief Complaint
Company & Health Card
Company
Health Card Provider
Account Number
Principal Card Holder's Name
Principal Card Holder's Birthday
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30 September - 06 October
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