PainBC Application

Health Care Provider Application Form

Please fill out the following form to apply to list your practice, service(s) or program on Pain BC's 'Find Help Near You' online database.

* indicates required field

Are you applying on behalf of an individual health care provider or for a clinic, organization or program?

Clinic, organization or program

Individual health care provider

Name of your practice / establishment / business

Required

HCP Name

Required

Primary Contact

If this is for a clinic/ business - please provide the name of the primary contact.
If this is for an individual - please provide the individual's full name.

First name

Required

Last name

Required

Website

Email

If this application is for an individual health care provider, please provide the individual's email address. If this application is for an organization, clinic or program, please provide the email address of the primary contact.

Required

Phone

Fax Number

Address

City

Please select a valid city.

Province

Please provide a valid province.

Postal Code

Postal code required.

Services Provided

Select all that apply.

Pain-related training and education

Please select all of the pain-related professional training and education you have completed. If you have completed professional courses or trainings not listed here, please list them in the ‘Other credentials’ section below.

Other Credentials

Please list any other relevant training or education you have completed, including any pain-related professional education not listed in the above question.

Pain BC professional education

Please indicate which Pain BC’s courses or workshops for health care providers you have completed, if any.

BC ECHO for Chronic Pain

Chronic Pain Management for Chiropractors

Chronic Pain Management for Occupational Therapists

Chronic Pain Management for Registered Massage Therapists

Pain Foundations for Allied Health Providers

Pain Foundations for Primary Care Providers

Gentle Movement and Relaxation

Service Area

Which BC communities do you serve? For many health services and providers, this may be a larger region than the city in which they are located.

Language

Please enter all languages, separated by a comma, for which your services are offered.

How can people access your services?

Walk-In

Appointment needed – self referral

Referral needed from health care provider

Accessibility

Wheelchair accessible

Accessibility parking / free parking

Assistance for parking pay

Braille signage

Deaf & hard of hearing line

Translation services

ASL translation

Service funding supports

Are your services covered by MSP

Yes

Partial

Other

Additional billing options

Private pay

Direct billing to insurance providers

Free services

Sliding scale

Other, provide details:

Which of the following insurers do you directly bill?

ICBC

WorkSafe BC

Desjardin

Pacific Blue Cross

Great West Life

Manulife

Sunlife

Other, provide details:

Business Description

Is there any other information you would like to publicly share about yourself or your services? Please note any information share here will be edited by Pain BC for clarity and to align with our submission criteria. (Character limit: 500)

Char Left:

Required

Comments

(This information will NOT be publicly visible)

Supporting attachments

Please upload documentation to support your registration with a regulatory body and proof of any certifications you have listed on this application.
(This information will NOT be publicly visible)

Allowable file types are JPEG, PNG and PDF. The maximum file size is 5 MB each.

Document 1

Document 2

Document 3