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Denies Maja - Specialist Sports Physiotherapist
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Intake form
Help us serve you better
Name
*
Email address
*
Phone number
What type of injury are you experiencing?
Please select at least one option.
Sprain
Strain
Fracture
Tendonitis
Shin Splints
Which sport do you participate in?
Please select at least one option.
Soccer
Rugby
Athletics
Basketball
Tennis
How long have you been experiencing this injury?
Select
Less than a week
1-2 weeks
3-4 weeks
More than a month
What treatments have you tried so far?
Please select at least one option.
Rest
Ice
Compression
Elevation
Medication
Physical Therapy
What are your rehabilitation goals?
Please select at least one option.
Pain relief
Increased mobility
Strength recovery
Return to sport
Prevent future injuries
Have you previously seen a physiotherapist?
Select
Yes
No
Do you have any medical conditions we should know about?
Additional questions or comments
Submit
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