Headache Clinics in Canada Intake Form

Headache Clinics in Canada Questionnaire

Thank you for your interest in having your clinic added to our Headache Clinic list. Please complete the intake form below. By submitting your clinic information, you consent to having it posted on our clinic locator.

Name*

First Last

Please enter your name or the point of contact.

Contact Email*

Your contact email is for internal communication only and will not be posted online. Your email will be added to our Migraine Minute monthly bulletin that includes information on new resources and programs Migraine Canada has available. We hope you will share our resources with your patients.

Provide the names of health care providers involved in headache care at your clinic.

What is the name of the clinic?*

Clinic Address*

Street Address Address Line 2 City Province Postal Code

Clinic Phone number*

Extension

Clinic Email

if available

Clinic Website

Clinic Fax number

Choose what describes the Clinic best.

Outpatient clinic, public
Outpatient clinic, private (out of pocket payments)
Academic, part of a University Department
Hospital-based (non-university)

How many physicians are part of the Headache Clinic?

1 (solo practice)
2-3
4 +

Which of the following work in your clinic?

Check all that apply

Please specify

Do you see?

check all that apply

Adults
Teens (12-18)
Children (<12)

Do you accept referrals for the following?

Check all that apply.

Migraine
Cluster headache
Facial pain / trigeminal neuralgia
Acute / new onset headaches <1 month
Post-traumatic headache, acute (concussion, mTBI)
Post-traumatic headache, chronic
Patients on long acting opioids for another pain

What medical services do you offer?

Check all boxes that apply.

Medical evaluation and follow-up
Emergency visits (<7 days access if needed)
Monoclonal antibodies
Medical cannabis
Opioid management

Which procedures do you offer?

Check all boxes that apply

Botox injections
Injections/nerve blocks, no radiology guidance
Injections/nerve blocks, with radiology guidance
Injections/nerve blocks with ultrasound guidance
IV medications / infusions
SPG blocks
Neurostimulation (implanted)

What behavioral services do you offer?

Please select only if the allied health care providers are working with you and you have a regular interaction with them, not if you refer to other independent clinics. Allied health care providers can be paid independently by patients. Check all that apply.

Please specify (Other)*

Do you provide medical expertise for insurance, disability etc?

Yes
No

Do you accept?

Check all that apply.

Patients who are self-referred
Referrals from physicians (GP and specialists)
Referrals through the hospital system only
Referrals from any health care provider
I don't take new patients

What is your usual waiting list for a usual headache referral?

Select best answer for usual referral, not for expedited access.

Do you engage in research?

Check all that apply.

Research led by industry
Original research from our team
No active research at present time

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