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

Online Forms

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

  • If you do not already have AdobeReader installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • THE NEW PATIENT INTAKE FORM DOES NOT NEED TO BE PRINTED. It is sent to our secure server upon completion. Other forms can be completed at the clinic before your appointment if you are not able to print.

New Patient INTAKE - Health History Form - Required
ALL NEW PATIENTS START HERE. No need to print this. Complete via the link below. This lets us know the history and current state of your health.

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

Form takes approximately 20 minutes to complete.

Welcome to our group. :) We look forward to helping you feel better.

Click here to fill out our New Patient Intake Form


Patient Consent Form - Required
Download & Print Form


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


Mental Health Questionnaire - Required only if applicable
This lets us know you current and prior stress level
Download & Print Form


Free Adobe Reader Download
Download the Free AdobeReader

We are here to provide you with the highest quality of care and cutting-edge medicine to completely eliminate your current pain. Call us today for a free consultation.