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Patient Information
Tolal Subscription Cost Quarterly:
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$120.00
First Name:
Last Name:
Sex:
Male
Female
Email:
Age:
Cobb angle (primary curve) in Degrees:
10 to 25 degrees
26 to 40 degrees
41 to 60 degrees
over 60 degrees
Do you wear a brace?
Yes
No
Are you currently under the care of a physician?
Yes
No
Do you have Back Pain?
Yes
No
Would you like to speak to one of our Doctors?
Yes
No
Has your Scoliosis Care professional approved you to perform exercise?
Yes
No
Without Scoliosis Care professional's approval, you couldn't proceed.
I want to make an appointment to speak with a doctor
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