Confidential Pain Management Consultation Form
Don’t let chronic pain keep you from enjoying life!
Pain can take the form of a stress-induced headache, a muscle group strained from sports activities, or be the result of an injury at work or an automobile accident. Pain is the most common symptom for which individuals seek medical help. Acute pain easily can evolve into chronic pain, which can become difficult to treat. Many commonly prescribed, commercially available pain relief medications help the symptoms associated with chronic conditions such as arthritis, fibromyalgia, migraine headaches, and other nerve and muscle pain, but they can also result in unwanted side effects such as drowsiness, dizziness or stomach irritation.
If you feel as though you need help with your chronic pain, fill out our consultation form below or click here to print out PDF version, then fax it back or bring it in. Your privacy is a top priority. This information is secure and is guaranteed to only go directly to the pharmacists.
For your convenience you can send your forms three different ways:
- Fill out the online Pain Management form below and sent it straight to us in our secure submission form.
- Print and fill out the PDF version for Pain Management and bring it in during your appointment.
- Print and fill out the PDF version for Pain Management and fax it to us at 760.834.6297.
Your privacy is a top priority; this information is secure and will only go directly to the pharmacists.
Please complete the form below:
Fields marked with * are required.