Tele-Rehabilitation Clinic Submission

If your clinic offers video assessments/treatments to your clients, please submit your information in the form below so that we can add you to our list.

Your Name *

Clinic Name *

We offer video assessments and/or treatments

Clinic Email Address *

Clinic Phone Number *

Clinic Website

Street Address *

Unit, suite, etc

City

State/Province

ZIP / Postal Code

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