SHOCK WAVE ONLINE ASSESSMENT Name* First Last Condition Name Name of the condition you are enquiring about. Brief description of symptoms and any treatments* As much information as possible is useful. Leave blank any areas you are unsure of. How long have you had the issue/injury?* Less than a month 1-6 months 1-3 years Over 3 years Do any of the following apply to you? Are you pregnant?* Yes No N/A Do you have a blood clotting disorder?* Yes No N/A Are you taking anti-coagulants?* Yes No N/A Have you received a Steroid injection in the last 6-weeks?* Yes No N/A Do you have a Pacemaker fitted?* Yes No N/A Are you under 18 years old?* Yes No N/A Contact Details Our team will review the details you provided and get back to you as soon as possible with an initial assesment of the benefits you might see from Shockwave Therapy. Please provide the best contact details for us to follow up with you. Your Email* Your Postcode* Disclaimer This service is provided for information only to help further your own research and should not be considered advice. Consultation with your own medical practitioner or healthcare provider is always recommended. We respect your privacy and no information will be shared with your express permission. CAPTCHA