New Patient Paperwork

Regen Med Pain Relief Clinics offers our patient form(s) online so they can be completed in the convenience of your own home or office.

  • All forms are PDF files. You will need AdobeReader® to view them.
  • If you do not already have AdobeReader® installed on your computer,
    Click Here to download.
  • Download the necessary form(s), print them out and fill in the required information.
  • Bring the necessary form(s) to your appointment.
  • Mandatory - Quality of Life Survey

    This lets us know about your health, wellness, and any previous care attempts.
    Download & Print Form

  • New Patient Intake - Health History Form - Required

    Complete via the link above. This lets us know the history and current state of your health.

    What questions, concerns, and goals, regarding wellness can we help you with? Let us know!

    The form takes approximately 20 minutes to complete.

  • Neuropathy Questionnaire - Required only if applicable

    This lets us know the history and current state of your health.
    Download & Print Form

  • Patient Consent Form - Required

    Click to Download & Print

  • Neck Pain Form- Required

    This lets us know the history and current state of your neck health
    Download & Print Form

  • Low Back Pain Form - Required

    This lets us know the history and current state of your back health
    Download & Print Form

  • Knee Pain Functional Scale - Required only if applicable

    This lets us know the history and current state of your knee health.
    Download & Print Form

  • Arm and Hand Questionnaire - Required only if applicable

    This lets us know the history and current state of your arm and hand health.
    Download & Print Form

  • Leg and Foot Questionnaire - Required only if applicable

    This lets us know the history and current state of your lower extremity health.
    Download & Print Form

OFFICE HOURS


Monday
8:30am - 5:00pm


Tuesday
8:30am - 2:00pm


Wednesday
8:30am - 5:00pm


Thursday
8:30am - 2:00pm


Friday
8:30am - 5:00pm


Saturday
8:30am - 2:00pm


Sunday
Closed

Regen Med Pain Relief Clinics

15720 W National Ave
New Berlin, WI 53151
(262) 785-5515