Title
Mr
Ms
Mrs
Mr & Mrs
Dr
Other
First Name
Last Name
Email Address
Contact Texting Number
Select the following symptoms of poor circulation that affect you:
Numbness or tingling in the hands and feet
Cold hands and feet
Swelling in the feet ankles and legs
Erectile Dysfunction
Memory loss and difficulty concentrating
Digestive issues
Fatigue and lack of energy
Joint pain and muscle aching
Skin color changes
Ulcers on the legs or feet
Varicose or spider veins
Select the following risk factors that apply to you:
Advanced Age (55+)
Overweight
Diabetes
History of smoking
Family history of heart disease
High blood pressure
Please summarize how poor circulation has negatively impacted your life, and we'll share with you how ECP Therapy can alleviate your issues.