First Name
Last Name
Phone
*
Email
*
Primary Concern
Pain relief
Stress reduction
Fat loss / body contouring
Improved mobility
Relaxation & wellness
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Preferred Treatment Approach
Massage therapy
Laser pain therapy
Red light therapy for fat loss
Combination of treatments
Not sure (need guidance)
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Current Pain or Stress Level (1–10)
*
3-5
5-7
7-9
9-10
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How much are you willing to spend on healing this pain pattern you’ve been experience,
