Joint rejuvenation icon Horizon Joint Revuvenation Centre Intake Form

Intake Form

If you still have questions please contact us directly.

Please note: At this time we are only accepting patients who are Canadian Residents.

Have you reviewed our intake process? If not, Click the button below:

    Gender*

    Date of Birth*


    Province*

    Country*


    Area of Concern*:

    Side Affected*

    When did the pain start?*

    Describe the pain:*

    Does the Pain Radiate?*

    Check any of the following that reduce pain:*

    Check any of the following that make the pain worse:*

    Check all that apply:*

    Check any medications you are taking:*

    Any treatments you have previously tried:*

    Do you exercise?*


    I have answered the questions above and read and understand the following:

    Which of the following refers to you:*