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David Butler DPT
Korey Derocher DPT
Dionne Butler NCMT
Charlene Nordhoff PTA
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Schedule FREE Discovery Visit
Talk to a Therapist
To Schedule An Appointment Call:
(801) 980-0860
Choose where the patient is and fill out the form COMPLETELY!
Straight to Eval
Eval to Treatment
Align Therapy
New Patients / Welcome Emails
Use this form for EVERY
New Patient who schedules
Straight to Eval
First Name *
Last Name *
Email *
Street Address 1
City
State
Postal Code
How did they hear about us? *
Please select one
Walk In
Dr Referral
WOM
Facebook
Google
Newspaper
Phone Number *
What type of patient? *
Scoliosis
Orthopedic
Where is the problem? *
Please select one
Scoliosis
Back
Neck
Knee
Shoulder
Foot/Ankle
Muscle Injury From Sport/Exercise
Postnatal Back Pain
Headaches/Migraines
Hip
Not Sure Where It’s Coming From
How Long Have You Suffered Or Worried? *
Haven't - This is prevention (not cure)
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Month
Long Enough
Seems Like Too Long (Years)
What Concerns You Most? *
Please select one
Not knowing what's wrong
Depending upon painkillers
Losing mobility or independence
The risk of facing surgery
Posture
Spinal curve progressing
Other Concerns (Specific)
No1 Thing Would Like To Achieve *
What does it stop you from doing? *
Birthday
PT Name *
Please select one
David Butler
Korey Derocher
Clinic Location *
Align Therapy
Time Of Appointment *
Day and Date of Appointment (i.e Wed 14th June) *
Appointment Booked By *
Please select one
Grace
Brittney
Dionne
Char
Korey
P.S Section *
Submit
CLINIC NAME
New Patients / Welcome Emails
Use this form for EVERY
Patient who schedules treatment
First Name *
Last Name *
Email *
Did they go ahead with the treatment? *
Yes
No
ONLY FILL THIS OUT IF THEY HAVE NOT GONE AHEAD WITH TREATMENT
Comments for follow up team
ONLY FILL THIS OUT IF THEY HAVE GONE AHEAD WITH TREATMENT
No1 Thing Would Like To Achieve
No. of weeks
No. of sessions p/week
PT Name
Please select one
David Butler
Korey Derocher
Clinic Location
Align Therapy
Time Of Appointment
Day and Date of Appointment (i.e Wed 14th June)
Appointment Booked By *
Please select one
Grace
Brittney
Dionne
Char
Korey
P.S Section *
Submit
Free Consultation
Consult to Eval
Align Therapy
Free Consult / Welcome Emails
Use this form for EVERY
Scheduled Free Consultation
First Name *
Last Name *
Email *
Street Address 1
City
State
Postal Code
How did they hear about us? *
Please select one
Walk In
Dr Referral
WOM
Facebook
Google
Newspaper
Phone Number *
What type of patient? *
Scoliosis
Orthopedic
What is the problem? *
Please select one
Scoliosis
Back
Neck
Knee
Shoulder
Foot/Ankle
Muscle Injury From Sport/Exercise
Postnatal Back Pain
Headaches/Migraines
Hip
Not Sure Where It’s Coming From
How Long Have You Suffered Or Worried? *
Haven’t – This is prevention (not cure)
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Month
Long Enough
Seems Like Too Long (Years)
What Concerns You Most? *
Please select one
Not knowing what’s wrong
Depending upon painkillers
Losing mobility or independence
The risk of facing surgery
Posture
Spinal curve progressing
Other Concerns (Specific)
No1 Thing Would Like To Achieve *
What does it stop you from doing? *
Birthday
PT Name *
Please select one
David Butler
Korey Derocher
Clinic Location *
Align Therapy
Time Of Appointment *
Day and Date of Appointment (i.e Wed 14th June) *
Appointment Booked By *
Please select one
Grace
Brittney
Dionne
Char
Korey
P.S Section *
Submit
CLINIC NAME
New Patients / Welcome Emails
Use this form for EVERY
Person who has Discovery
First Name *
Last Name *
Email *
Did they go ahead with the eval? *
Yes
No
ONLY FILL THIS OUT IF THEY HAVE NOT GONE AHEAD WITH THE EVAL
Comments for follow up team
ONLY FILL THIS OUT IF THEY HAVE GONE AHEAD WITH THE EVAL
PT Name
Please select one
David Butler
Korey Derocher
Clinic Location
Align Therapy
Time Of Appointment
Day and Date of Appointment (i.e Wed 14th June)
Appointment Booked By *
Please select one
Grace
Brittney
Dionne
Char
Korey
P.S Section
Submit
Tap to Request More Information!
HOME
ABOUT
▼
FAQ
THERAPISTS
▼
David Butler DPT
Korey Derocher DPT
Dionne Butler NCMT
Charlene Nordhoff PTA
SERVICES
▼
SCHROTH METHOD
SCOLIOSIS
SURFACE TOPOGRAPHY
SCHEUERMANN’S KYPHOSIS
BACK PAIN
ASTYM
RUNNING REHAB
MASSAGE THERAPY
TELEHEALTH
BLOG
▼
The Scoliosis Experience Podcast
PATIENTS
▼
RUNNER PORTAL
SCOLIOSIS PORTAL
▼
SCOLIOSIS EQUIPMENT
NEW PATIENT PAPERWORK
STORE
PROVIDERS
CAREERS
CONTACT