BUDDHAS PALM PHYSICAL THERAPY APPLICATION FORM
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BUDDHAS PALM PHYSICAL THERAPY HOME CARE SINCE 2009
ABOUT BUDDHAS PALM
PERSONAL INFORMATION
Full name (First name, Middle initials and surname) *
Address *
Landmark address *
Age *
Gender *
Cellphone number *
Telephone number *
HEALTH INFORMATION
What is the problem or general health condition *
Required
CONDITION TREATED
Please specify the problem or condition *
When did the condition started *
MM
/
DD
/
YYYY
Do you have any referral *
Sample treatment advice or given by a doctor (if none our PT will design a treatment program) *
Required
SAMPLE INSTRUMENTS
Whe do you plan to start the treatment *
MM
/
DD
/
YYYY
How many session advice by a doctor or your previous therapy *
Required
What is the day you wish to booked *
Required
How did you find our site *
Required
Male or license PT *
Required
RATE FOR PHYSICAL THERAPY PER SESSION/DAY *
Required
PACKAGE DISCOUNT MAY 2019
PACKAGE DISCOUNT FEES (FULL PAYMENT ONE WEEK BEFORE TREATMENT THRU BPI /REMITTANCE *
Required
OTHER advance therapy for Muscle Joint and Bone problem *
Required
PLEASE SUBMIT THEN CALL US AFTER FILLING UP THIS FORM
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