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Damien Howell Physical Therapy
Motion Analysis Service - Registration

Thank you for your payment. Your transaction has been completed, and a receipt for your purchase has been emailed to you. You may log into your account at www.paypal.com/us to view details of this transaction.

The Process

  • Enter coupon (if you have one)
  • Pay at Paypal
  • Register with your information
  • Login
  • Upload your video

Registration

Please provide the information below. You will then proceed to upload your video.


First Name :
Middle Initial :
Last Name :
Address 1:
Address 2:
City:
State:
Zip:
Home Phone:
Work Phone :
Email:
Email Confirmation:
Create Account Access
Create Username:
Create Password:
Confirm Password:
I am requesting a slow motion video analysis to:
Improve performance
Prevent Injury
Diagnosis and/or treat injury
Other reason - please explain
Briefly describe the problem for which you are seeking slow motion video analysis:



Phone: 804-285-6818      E-mail:
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