New Client Form

by Dr. Sebastian Gonzales | Nov 10, 2024 | Pain Management in Orange County | 0 comments

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First Name*

Last Name*

Phone*

Are you over 18 years old?*

Yes

Email*

Are you local to the Southern CA area?

Yes

How did you hear about us?*

Youtube Video

Yelp

Web Search for our Articles (google, bing, etc.)

Referred by someone

Restoring Human Movement Podcast

If you were referred, who can we thank for sending you in?

What are you wanting help with?

Back Pain

Groin/ Hip Pain

Shoulder Pain

Neck Pain

Other

If other, please specify.

How long have you been dealing with this issue?*

Weeks

Months

Years

What concerns you most about your condition?*

Not knowing what's wrong

Depending upon painkillers

Losing mobility or independence

The risk of facing dangerous surgery

Not being able to workout/stay active

Not being able to play sports

Are you committed to finding a long-term solution to your pain?*

Yes

What's the #1 thing you'd like to achieve!?*

What type of care are you looking for?*

A comprehensive rehabilitation plan customized specifically for my goals

Just a quick adjustment

Injury prevention

Performance

What is your biggest objection to committing to a plan of care?

Time

Cost

I have none

Other

If other, please specify…

Are you willing to invest in yourself and your health?*

Yes

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Who uses a Huntington Beach Chiropractor?

Most people whom have used a Huntington Beach Chiropractor are very happy with the results even after a few sessions. Active Release® Chiropractors are used by Pros from nearly all major sports. Our Huntington Beach Chiropractor is active and athletic & knows how to treat sports injuries from personal experience. Check out our patient testimonials… they tell it all! Afraid of going to a Huntington Beach Chiropractor... You're in the right place!