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Relief. Restoration. Renewal.

Request a new patient appointment.

Three quick steps. Our team will reach out to schedule your first visit.

Three quick steps Provider referral required

Request received

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Questions? Call (602) 603-2282

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Choose the option that best describes your visit. The rest of the form only asks for what we need for that type of care.

Patient type

First Name * Last Name * Date of Birth * Home ZIP Code Mobile Phone Number * Email Address *

Sex

Preferred Contact Method

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 send me practice news and offers by text and email.Separate and optional. By checking this box I agree to receive marketing text messages from Canyon Pain Center at the mobile number I provided and marketing emails 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 messages a month at most. Message and data rates may apply to texts. Reply STOP to cancel texts, HELP for help. Every email has an unsubscribe link at the bottom, and I can also unsubscribe by replying or calling the office. This is separate from texts and emails about my own care and appointments, which I will keep receiving either way. No mobile information is shared with third parties or affiliates for marketing or promotional purposes, and my email address is not sold or shared with third parties for their own marketing. See our Text Message Terms and Privacy Policy.

Both boxes are optional and neither is a condition of treatment. Leave them unchecked and we will still reach you about this request by phone or email.

Preferred Language

Do you need an interpreter?

Do you have a referral currently?

What is the main reason you are seeking pain-management care?

How long have you had this pain?

Briefly describe your pain and how it affects daily life. Include the main body area affected and one or two activities it limits, such as walking, sleeping, working, or driving. {{ descLeft }} characters remaining

Are you currently taking prescription pain medication?

Which medications and doses? (optional)

Type of accident

Injured areas (select all that apply)

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Have you received any treatment for this injury yet?

Where and what kind of treatment? (optional)

Do you have an attorney for this case?

Attorney name Law firm Attorney phone Attorney email (optional)

You can still be seen without an attorney. Our team will explain your options when we call.

Accident claim

If a claim has been opened with an auto or liability carrier, share what you have.

Claim carrier (optional) Claim number (optional)

Employer name Employer phone (optional)

Did you report the injury to your employer?

Status of your workers’ comp claim

If your claim was denied, submit this request anyway. Our team will review your options with you.

Claim and adjuster details

Share what you have.

Workers’ comp carrier (optional) Claim number (optional) Adjuster name (optional) Adjuster phone (optional) Adjuster email (optional)

The questions on this step depend on your patient type. Choose Pain Management, Personal Injury, or Workers’ Compensation on step 2 to see them.

Preferred appointment days

Preferred appointment time

Have medical records to share?

After you submit, we’ll send you a confirmation email. Simply reply to that email with any recent imaging reports, clinic notes, or other records you have. Don’t have your records? That’s okay. We can request them from your previous provider, or you can bring them to your visit.

How did you hear about us? (optional)

Please tell us where you heard about us.

Please complete the following before continuing:

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We could not send your request. Please try again or email info@canyonpaincenter.com.

Our team reviews every request and will contact you by your preferred method to confirm scheduling.
Already a Canyon Pain Center patient? Request your next appointment here.

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.

Request a new patient appointment.

Request received

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Text messages and emails are optional