We'll get you feeling better as soon as possible
(1) Kindly complete the questions to follow to better help us understand your pain symptoms. (2) We will review your Urgent Request for Treatment and get back to you as soon as possible. (3) Our Urgent Care days are Wednesdays & Thursdays weekly (4) We will be scheduling appointments in order of priority sequence based on level of urgency (we will book you in any day of the week where we have an available appointment, but Wednesdays & Thursdays are the days we aim to fill up with Urgent Care).
Would this be your initial visit?
Yes
No
Important: We are experiencing a higher volume of Urgent Care Requests and we ask for your patience while we try our best to see all patients as soon as possible. Thank you.
(You are still welcome to let us know your current pain symptoms and situation and we will email you that we have received it. We just may not be able to help you as quickly as you would hope, and encourage you to continue to look for a clinic that can help you sooner) We will also contact you to advise of a few options for you.
What is your name?
*
What are you have problems with?
*
Chronic pain
Acute pain
Referred pain /Nerve pain
Debilitating pain
Something else
Other
What is the location of your pain?
*
What are your pain symptoms?
*
What is your pain intensity (right now)?
*
1
2
3
4
5
6
7
8
9
10
Best
Worst
1 is Best, 10 is Worst
When did your pain start? (approximately)
*
-
Month
-
Day
Year
Date
Are you currently doing any other types of Treatment for this concern?
*
Massage Therapy
Physiotherapy
Acupuncture
Chiropractic
Osteopathy
Medical Doctor
Over-the-counter medications
Prescribed medications
Exercise
Ice
Heat
Muscle Creams
Nothing else
Other
Contact Information:
Tell us the best way to reach you.
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Preferred method of contact?
*
Email
Phone /Text
What is the best time of day to reach you?
*
Morning
Afternoon
Evening
Lastly, please indicate which days/times are best suitable for your schedule to come in for Treatment:
Submit
Should be Empty: