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EMERGENCY? CALL 289-724-PAIN (7246)
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Comprehensive Pain: What is it?
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Chronic Pain Rapid Access Clinic – Self Referral Form
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Patient Information
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3
Name
*
First
Last
Email
*
Phone
Next
Are you experiencing chronic pain related to cancer?
*
Yes
No
Which clinic would you like to visit?
*
Oakville Clinic – 245 Wyecroft Road, Unit 1
Mississauga Clinic – 6981 Millcreek Drive, Unit 2
St. Catherines Clinic – 300 Fourth Avenue, Unit D
Orangeville Clinic – 33A Broadway Avenue, Unit 1
Niagara Clinic – 6360 Lundy’s Lane
Kitchener Clinic – 800 King Street West
Hamilton Clinic – 701 Main Street West, Unit 100
Windsor Clinic – 2464 Howard Avenue, Suite 106
Welland Clinic – 95 Lincoln Street, Unit 1
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How did you hear about us?
Social Media
Search Engine (ex. Google)
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Dental Clinic
Physiotherapy/Massage Clinic
Chiropractor
Pharmacy
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Do you currently have a family doctor?
*
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No
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EMERGENCY? CALL 289-724-PAIN (7246)
Home
About
Comprehensive Pain: What is it?
Our Doctors
Our Clinics and Locations
Locations
Patients
Family and Caregivers
Patient Information & FAQ
What Is Chronic Pain?
What Is a Pain Clinic?
Where Does It Hurt?
Am I A Candidate?
Conditions We Treat
Programs/Services
Integrative Pain Management
Comprehensive Pain Management
Interventional Pain Management
Medical Management
Joint Pain Program
Medical Cannabis
Regenerative Medicine Program/PRP
Mindfulness Program
Healthcare Providers
Patient Referral
Career Opportunities
RAPID ACCESS CLINIC
PATIENT QUESTIONNAIRE
