Practitioner Match Questionnaire

Name

First Last

Phone

1. Please describe the challenge you are facing in 200 words or less.(Required)

2. Have you seen any of these allied health professionals in the past for treatment:(Required)

Acupuncturist

Chiropractor

Massage Therapist

Physiotherapist

I have not seen any allied health professionals

Other

3. Do you prefer a male or female practitioner?

Male

Female

Either

4. Is there anything else you would like us to know?