Interventional pain intake that captures duration and prior treatment
Patients tell you where the pain is, how long it's lasted, and whether they've already tried physical therapy or medication, then upload MRI or X-ray results, so your team can see who's ready for an interventional workup before a slot is booked.
The exact intake your interventional pain consultation leads complete
This is the real 6-question guided intake for Interventional Pain Consultation — the same flow your customers finish before you ever pick up the phone.
What a qualified interventional pain consultation lead should tell you
An initial specialist evaluation of chronic or severe pain to determine candidacy for procedural treatments such as injections, nerve blocks, or ablations, based on pain location, duration, and prior conservative care.
- Main Area Pain Located
- Long Have Been Experiencing
- Already Tried Treatments Like
- Have Recent Imaging Results,
- Doctor Referred This Consultation,
- This Pain Affecting Daily
The questions your team needs answered
Every interventional pain consultation intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Where is your main area of pain located? | Pain location determines which specialist track or procedure type the consultation is likely to focus on, such as spine versus joint injections. |
| How long have you been experiencing this pain? | Longer pain duration scores higher since it more often reflects a chronic case that has moved past initial self-management. |
| Have you already tried treatments like physical therapy or medication for this pain? | A 'yes' to prior physical therapy or medication scores higher because completed conservative treatment is a common prerequisite for interventional procedures and their authorization. |
| Do you have recent imaging results, such as an MRI or X-ray, related to this pain? | Knowing whether imaging already exists lets the provider prepare for a diagnostic conversation instead of ordering new scans at the first visit. |
| Has a doctor referred you for this consultation, or are you seeking one on your own? | Referral status tells staff whether a physician has already directed the patient toward this consultation or if outreach and referral paperwork may still be needed. |
| How is this pain currently affecting your daily activities? | Segments the lead so you can route, price, and prioritize it correctly. |
How Cliont scores interventional pain consultation leads
Every answer is weighted automatically — no manual review required.
Value signals
- Less than 1 month
- 1 to 3 months
- More than 3 months
- Already Tried Treatments Like: yes
- Minimal impact
- Moderate impact, some limitations
Urgency signals
- Severe impact, major limitations
See the lead your team receives
Interventional Pain Consultation Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for interventional pain consultation workflows
| Cliont capability | Interventional Pain Consultation application |
|---|---|
| Conditional document capture | The MRI/X-ray upload prompt only appears when a patient confirms imaging exists, keeping the form short for those without records yet. |
| Referral-based routing | Physician-referred and self-seeking patients can be tagged differently in the CRM based on the referral-status answer, so staff know who may still need a referral on file. |
| Weighted scoring by chronicity and prior care | Duration and prior-treatment answers combine to push longer-standing, previously-treated pain cases higher in the queue than brand-new, untreated complaints. |
| Video intake widget | Lets patients describe pain location and how it affects daily activity in their own words before the visit, giving the provider more context than the multiple-choice answers alone. |
Common interventional pain consultation lead scenarios
Self-referred with imaging in hand
Patient found the practice on their own, has already tried physical therapy, and uploads a recent MRI showing disc involvement, giving the front desk enough to schedule with confidence.
Physician-referred chronic back pain
A doctor referred the patient after months of unresolved back pain, but no imaging has been sent over yet, so the intake flags a request for records before the visit.
New-onset nerve symptoms, no treatment yet
Numbness and tingling started less than a month ago and the patient hasn't tried medication or PT, signaling this consultation may need to route toward conservative care first.
Joint pain with minimal daily impact
Self-seeking patient reports knee pain with only minimal impact on daily activities and no prior treatment attempted, useful for triaging lower-urgency requests without turning them away.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More pain management intake templates
Interventional Pain Consultation lead-intake FAQs
Does the intake tell us if a patient was referred by a doctor or is self-seeking?
Yes, the referral question separates physician-referred patients from those seeking a consultation on their own, so staff know upfront whether referral paperwork needs to be requested before scheduling.
What happens if a patient hasn't tried physical therapy or medication yet?
The intake records their answer to the prior-treatment question, and since it carries less weight than a 'yes' response, those leads score lower and can be routed toward conservative care guidance rather than an immediate procedural slot.
Can patients upload their MRI or X-ray during intake instead of bringing it to the visit?
Yes, the form asks whether recent imaging exists and lets patients attach it directly, so the consulting provider has diagnostic context before the appointment starts.
How does how long someone has had pain affect their lead score?
Duration is weighted on a rising scale, from less than a month up to more than three months, since longer-standing pain is more often associated with completed conservative care and readiness for interventional evaluation.
Does the intake distinguish between back, neck, joint, and nerve pain?
Yes, patients select their main pain location from those options, which lets you route leads consistently with related intake pages like Back Pain, Neck Pain, Joint Pain, and Nerve Pain.
How does the daily-impact question factor into scoring?
Patients rate whether the pain causes minimal, moderate, or severe limitation, giving your team a quick read on functional impact alongside duration and treatment history, without the form making any clinical determination on its own.
Turn interventional pain consultation visitors into qualified patients
Give every interventional pain consultation visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.