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Pre-Assessment Form Durham

Pre-Assessment Form

Client Application
Emergency Contact
Insurance
How much coverage do you have for:
Past Medical History

Do you have currently, or have you ever had in the past, any of the following:

Medical Information
Remember to include with your application the Physicians Clearance Form - required for acceptance into the Aim2Walk program

Please describe your current physical abilities:

Thank you for completing and submitting this application. A member from our team will be in touch shortly to schedule a tour and/or a free consultation with our Clinic Director. If you need to reach us, you can call us directly at 905-440-4939.

Please note, your application will remain on file for 1 year following it's submission to NeuroChangers

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