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New Client Questionnaire

Please note this form must be completed in order to confirm your appointment.

At Pacific Pain and Wellness Group we take great strides to reserve dedicated patient times for appointments. It is for this reason that we collect credit card information ahead of time.
       
First Name
Last Name
Date of Birth
Address
Address 2
City
State
Zip
Phone Number
Email Address
Please briefly explain your reason for seeking treatment
How did you hear about this practice?
Please list any prior medical diagnosis
Please list all medications you are currently taking
Are you interested in Ketamine Infusions?
Are you interested Transcranial Magnetic Stimulation?
Please list any prior psychiatric medications taken including length of time, dosage, if it worked, and what if any side-effects you had.
Are you requesting an evaluation or treatment for ADHD?
In the past several years, have you had any suicide attempts, self-harm, thoughts of suicide or of harming yourself/others?
Have you had or currently have any substance abuse? Please briefly explain each episode.
New Patient Appointments require 2 Business Day notice (48 Hours) or will incur a fee of $275.00
Follow Up Appointments require 1 Business Day notice (24 Hours) or will incur a fee of $125.00
Therapy Visits require 1 Business Day notice (24 Hours) or will incur a fee of $125.00
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID/CVC

By providing the aforementioned details, I acknowledge that if I cancel, reschedule or miss my new patient appointment with less than a 48-hour notice or my follow-up/therapy appointment with less than a 24-hour notice, my credit card will be charged $275 for new appointments or $125 for follow-up/therapy appointments, constituting the full appointment fee. No charges will be applied if cancellations are made with proper notice.
By checking this box, I agree to the card on file being charged for appointment copays. I understand that deductibles, non-covered services paid out of pocket, and portions of bills not covered after insurance has paid will not be charged on this card until I provide approval at the time of the transaction.