Dawn Chimento Physical Therapy, PC -

So That We Can Serve Your SPECIFIC Needs, Please Fill Out This Quick & Easy Form And Show Us EXACTLY How You Want Us To Help YOU… The more we know about you, the better we can help you…

First Name*

Last Name*

What Service Do You Need?*

Physical Therapy

Total Body Diagnostic

Performance Assessment - (Prevent & Progress)

Video Visit

Massage Therapy

Health Coaching

Private Yoga

Corporate Yoga/Wellness

I'm not quite sure...

Free 1/2 Hour Discovery Visit

Please Choose Your Ideal Day For An Appointment*

Preferred Time*

Where Does It Hurt?*

If Other Please Describe Here (optional):

How Long Have You Struggled with This Problem?*

Haven't - This is prevention (not cure)

A Few Days

1-2 Weeks

2-4 Weeks

1-3 Months

Long Enough (4+ months)

Seems Like Too Long (Years)

What Does It Stop You From Doing?*

What Concerns You The Most That Makes You Want To Consider Physical Therapy?*

The #1 Thing You Would Like to Achieve From Physical Therapy*

So we can provide the pricing and availability of the service you have requested, please tell us how best to contact you.

Phone*

Email*