Intake form

Name *

Email address *

What is your primary reason for visiting lakeside pain center?

Please select at least one option.

Chronic back pain

Chronic neck pain

Joint pain

Nerve pain

Post-surgery pain

How long have you been experiencing this pain?

Please describe the pain you are experiencing.

What treatments have you previously tried?

Please select at least one option.

Physical therapy

Medication

Chiropractic care

Alternative therapies

Surgery

Do you have any allergies?

What is your current medication regimen?

Have you undergone any previous pain management procedures?

Please select at least one option.

Epidural injections

Radiofrequency ablation

Spinal cord stimulation

SI joint fusion

What is your preferred method of communication?

Do you have a history of any of the following conditions?

Please select at least one option.

Diabetes

Heart disease

High blood pressure

Mental health issues

None of the above

What is your insurance provider?

What is your date of birth?

Which service or services are you interested in?

Please select at least one option.

Epidural injections

Facet Joint Radiofrequency ablation

Spinal cord stimulation

Basivertebral nerve ablation

Kyphoplasty

Minuteman

Additional questions or comments

Lakeside Pain Center