Complete your patient intake.

Canyon Pain Center requires a referral from a medical provider before establishing a new pain-management patient. You can submit this request now — our team will confirm whether your referral has arrived and help you request one if it has not.

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Text messages and marketing emails from Canyon Pain Center are optional and are never a condition of treatment. You can opt in to each of them separately on the first step, where the full terms appear next to every checkbox. See our Text Message Terms and Privacy Policy.

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This form is not for emergencies. If you have chest pain, trouble breathing, new loss of bowel or bladder control, numbness in the groin area, new or rapidly worsening weakness, fever with severe back or neck pain, severe symptoms after trauma, or thoughts of self-harm, call 911 or go to the nearest emergency department.

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Your information is protected. Canyon Pain Center is a healthcare provider covered by HIPAA. This form is sent over an encrypted connection to our patient management system, which is contractually required to safeguard your information, and your answers are handled in accordance with our Notice of Privacy Practices. Please answer only what the questions ask — bring detailed records, imaging, or test results to your visit rather than entering them here.

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

Sex Assigned at Birth *

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Preferred Contact Method *

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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 your care by phone or email.

Preferred Language * Select… English Spanish Other

Do you need an interpreter? *

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

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How long have you had this pain? *

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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? *

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List the medication name and prescribing clinician, if known. (optional)

Are you currently experiencing any of the following? *

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Your symptoms may require immediate or emergency evaluation. Call 911 or go to the nearest emergency department. Do not wait for an appointment-request response.

Do you have health insurance for this visit? *

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We are out of network with all insurance plans and bill select PPO plans directly on that basis. Telling us your plan lets our office verify it and explain your costs before the visit.

Insurance company name (optional)

Preferred appointment days *

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Preferred appointment time *

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Review the Notice of Privacy Practices before submitting.

How did you hear about us? (optional) Select… Google Search Google Maps Bing AI - ChatGPT AI - Claude AI - Other Referred by a doctor Referred by family or friend Insurance directory Social media Other Please tell us where you heard about us.

Please complete the following before continuing:

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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.