"*" indicates required fields What are you seeking treatment for?* Knee pain/injury Back pain/injury Neck pain/injury or headaches Arm or shoulder pain/injury Other Which location is nearest to you?* West Bloomfield, MI 48323 St. Clair Shores, MI 48080 Rochester Hills, 48307 Shelby Township, MI 48315 Berkley, MI 48072 HiddenContact Info SectionName* First Last Email* Phone*Preferred Times Early morning Late morning Around noon Early afternoon Late afternoon Other Other Preferred Times HiddenWavier SectionWaiverI acknowledge that I am not including any protected health information (PHI) in my inquiry. I understand that any such information should be presented in person or securely over the phone with my health care provider. PHI, as defined by HIPAA (Health Insurance Portability and Accountability Act) includes, but is not limited to, any information that relates to 1) the past, present, or future physical or mental health or condition of an individual, 2) the provision of health care to an individual or 3) the past, present, or future payment for the provision of health care to an individual that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual. I consent to allow any and all electronic communications with this recipient. These communications include this form and all others on this website, emails, text messages and website comments. I understand that electronic communication is not secure and that any information that I provide here may be visible to third parties or unintended recipients. I waive my rights under HIPAA to the extent that they can be waived and, in the event that any PHI is provided within this message or related messages, do not hold the recipient liable to any breaches or disclosures of the information provided in this message. I acceptCommentsThis field is for validation purposes and should be left unchanged.