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Client Form & Payment - Platinum Package

Please check yes or no to following questions:

Do you have soreness or discomfort in the wrist/forearm/elbow?
Is there soreness or discomfort in the shoulder?
Is there soreness or discomfort along the neck/shoulder region?
Is there soreness or discomfort in the low back?
Do your eyes become sore/tired at the end of the day?
Do you experience headaches related to prolonged screen use?

Four photos and 1 optional photo: Have someone take photographs of you using a digital camera or phone camera. Take a picture at 4 different angles while the client is sitting at the workstation/desk.

**Photos should be discreet and obstruct any private or company information.

 Full body View from the Right, Portrait Orientation
Upload supported file (Max 15MB)
 Full body View from the Back, Horizontal/Landscape Orientation
Upload supported file (Max 15MB)
 Full body View from the Left, Portrait Orientation
Upload supported file (Max 15MB)
 Full body View from overhead, Horizontal/Landscape Orientation
Upload supported file (Max 15MB)
 Optional photo of bottom of chair showing wheels
Upload supported file (Max 15MB)
All exercises and health education with the Revitalize Program are recommendations ONLY and do not replace your doctor prescribed treatment plan. Consult a physician before beginning any exercise regimen or wellness program. Do you consent to program at your own risk?

**90 days access of our (members) only industry-leading (Revitalize Program*) included after check-out.

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