logo

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
Address
Address 2
City
State
Zip
Country
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 $175.00
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 entering the information above, I understand if I cancel or miss my appointment less than 48 hours prior to my appointment or no show/miss my appointment, my credit card will be charged $275 for new appointments, $175 for follow-up appointments, or $125 for therapy appointments, the full amount of the appointment. We do not charge the card if an appointment is cancelled 48 hours in advance.