Who are we scheduling?
First name * Last name * Date of birth * Home ZIP code (optional) Mobile phone * Email *
Sex (optional)
✓ Female✓ Male✓ Prefer not to answer
Best way to reach you *
✓ Phone call✓ Text message✓ Email
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 .
