User: Service Request

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Service Request

Note: Our professional services are exclusively for patients with physical disabilities resulting from Brain, Spinal cord, or Peripheral Nerve disorders.
Please do not fill out this form if your primary concern is Pain.
If it is not listed here, you should create a profile for him/her first.
Please select “Not Listed” if your country is not listed here.

Selecting Not Listed means that unfortunately, we have no collaborating practitioner in your area and our tele-rehabilitation services is not accessible at present time.

Since you have already created a profile for this patient, we have noted their country and province of residence and will begin our efforts to provide services in that area. We will update you as soon as we have positive news.

If you have selected Not Listed by mistake, you can edit your selection and proceed.