Intake form

Help us serve you better

Name *

Email address *

Phone number

Date of birth

Gender

Address

Are you currently experiencing any of the following symptoms?

Please select at least one option.

Pain

Numbness

Weakness

Tingling

What type of therapy are you interested in?

Please select at least one option.

Physiotherapy

Rehabilitation

Sports injury therapy

Musculoskeletal conditions therapy

Electrotherapeutic modalities

Have you previously received any physiotherapy or neurodiagnostic treatment?

If yes, please provide details about your previous treatment.

Are you currently taking any medications?

Do you have any known allergies?

How did you hear about us?

Additional questions or comments

Sorry, we were not able to submit the form. Please review the errors and try again.

Azeem Electro-neurodiagnostic and Physiotherapy Center