Request an established patient appointment.

Use this form if you have already been seen at Canyon Pain Center and need to schedule your next visit. If you have never been a patient here, start with the new patient request form instead — a provider referral is required to establish care.

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First name * Last name * Date of birth * Mobile phone * Email *

Best way to reach you *

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Not for emergencies. For chest pain, trouble breathing, new or worsening weakness, or thoughts of self-harm, call 911.

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Text messages and emails are optional

Yes, text me about my appointment and my care.By checking this box I agree to receive text messages from Canyon Pain Center at the mobile number I provided about my appointment request, scheduling, reminders, paperwork, and my care. Consent is not a condition of treatment or of any purchase. Message frequency varies. Message and data rates may apply. Reply STOP to cancel, HELP for help. No mobile information is shared with third parties or affiliates for marketing or promotional purposes. See our Text Message Terms and Privacy Policy. Also text me occasional practice news.Separate and optional. By checking this box I agree to receive text messages from Canyon Pain Center at the mobile number I provided about new services and providers, office updates, and health information for our patients. Consent is not a condition of treatment or of any purchase. A few messages a month at most. Message and data rates may apply. Reply STOP to cancel, HELP for help. No mobile information is shared with third parties or affiliates for marketing or promotional purposes. See our Text Message Terms and Privacy Policy. Email me practice news and offers.Separate and optional. By checking this box I agree to receive marketing emails from Canyon Pain Center at the email address I provided about new services and providers, office updates, patient offers, and health information for our patients. Consent is not a condition of treatment or of any purchase. A few emails a month at most. Every email has an unsubscribe link at the bottom, and I can also unsubscribe by replying or calling the office. This is separate from text messages and from emails about my own care and appointments, which I will keep receiving either way. My email address is not sold or shared with third parties for their own marketing. See our Privacy Policy.

All three are optional and none of them is a condition of treatment. Leave them unchecked and we will still reach you about this request by phone or email.

What is this visit for? *

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When were you last seen here? *

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Who would you like to see? *

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Anything we should know before the visit? Optional, and please keep it brief. This form is not a secure channel for urgent clinical concerns — call the office for those.

Which days work best? *

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Morning or afternoon? *

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It is okay to contact me by phone or email about this request. *

Just a couple of things:

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Privacy and HIPAA notice. Canyon Pain Center is a covered entity under the Health Insurance Portability and Accountability Act (HIPAA). Information you submit through this form is protected health information and is transmitted over an encrypted connection to our patient management system, which is contractually required to safeguard your information and to use it only for the services it performs for us. We use it to respond to your request and arrange care. We never sell it, and we send practice news only if you opt in on this form. Full details of how your information may be used and disclosed, and of your rights, are set out in our Notice of Privacy Practices and Privacy Policy. This form is not monitored continuously and is not a secure channel for urgent clinical concerns — call the office at (602) 603-2282, or 911 in an emergency.