Contact Direct Physical Therapy

Name *

First Name

Last Name

Phone *

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Terms and Conditions *

I agree to, my submitting any type of contact to or form(s), I am in agreement in receiving contact from Direct Physical Therapy about communication of services via any database like SMS/text messages, email, and all other communications. I need to state CLEARLY STOP communications with the proper form in order to fully stop receiving messages from Direct Physical Therapy. I realize, I MUST BE AT LEAST 18 years old or older to receive communications from Direct Physical Therapy.

Date of Birth *

MM

DD

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