Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Email
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Phone
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(###)
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Emergency Contact Name
Emergency Contact Number
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please give an in-depth overview of the specifics of the current or long term injury, pain & or discomfort you are or have been dealing with and for which is the reason for you contacting Odyssey.
Please give and in-depth overview of the length of time that this issue has been a problem for yourself.
Please give and in-depth overview of within this time what protocols you have tried to fix this issue? (i.e Nothing, Physiotherapy, Chiropractic, Resting, Anti-Inflammatories, Surgery etc).
Please give and in-depth overview of why you think these things haven’t worked for you or have had little long term success.
On a scale of 1 - 10, how much of a priority is this for you to fix? (1 = Not at all , 10 = No. 1 priority for my physical & mental health)
1
2
3
4
5
6
7
8
9
10
Please give an in depth overview of what your main goal is to achieve with this over the next 12 months?
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Please give a full list of all the training equipment you have currently at your access to at home (this will assist in the remote programming system of Odyssey).
Do you give consent for Odyssey to use photos or videos of yourself for social media marketing purposes?
Please give in as much detail as possible any more relevant information you see necessary for us to know about yourself. (i.e injury history, sports background, hobbies, job description)
Please check this box to confirm that you have read and accepted the Terms & Conditions (see below) for the services provided by Odyssey Southwest
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