Pain Relief

Please complete the form below and rate your percentage of pain relief for six consecutive hours post-injection.
Your pain rating will be available at your next appointment with Dr. Clark.

Dr. Clark's Pain Relief Log

Date of Your Injection

Patient's Name(Required)

First Last

Date of Birth(Required)

First Hour(Required)

Second Hour(Required)

Third Hour(Required)

Fourth Hour(Required)

Fifth Hour(Required)

Sixth Hour(Required)

Additional Comments

Dr. Clark's Pain Relief Log

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