New Patient Intake

Mind in Motion PA / Pain Relief KC

Your Information

First Name *

Last Name *

Date of Birth *

Phone *

Email *

Address

City

State

Zip

Emergency Contact

First Name

Last Name

Phone

How did you hear about us?

Tell us what's going on *

Pain level right now

0 — None 10 — Worst

How long has this been going on? *

Based on what you told us, we have a few follow-up questions.

The fee for this visit is $100. Follow-ups range from $50–$100 depending on the length of the visit needed.

I acknowledge the fee and consent to treatment. *

Signature *