Video Group Clinic Self-Referral Form

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All questions marked with a * are mandatory

To register an interest in our Virtual Group Consultations, please complete the following form.

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Personal Details
Please double check you've entered the correct email address
May be used to identify you
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Virtual Group Consultation
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Questionnare
Your Current Weight (Please Specify Unit): *
Your Current Height (Please Specify Unit): *
Level of Activity: *
How is Your Posture?: *
What is Your Smoking Status?: *

The visual analog scale for pain is a straight line with one end meaning no pain and the other end meaning the worst pain imaginable. 1 is the lowest and 10 is the highest.

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