Thank you for your interest in referring a new patient to us. For your convenience, we have compiled a list of the necessary procedures and paperwork that will enable us to offer your patient the best possible care. Please complete each item prior to scheduling an appointment. If you have any questions, please call 261-4988.
Checklist for pain management
Surgical Procedure Only (No consultation or initial visit)
1.
A written description of the specific procedure requested.
2.
Chart notes of most recent two to three clinic visits.
3.
Recent MRI or CT Scan report.
Consultation/New Patient Referral:
1.
Chart notes of most recent two to three clinic visits.
2.
Demographic sheet.
3.
Referral note. One to three sentences indicating reason for referral.
4.
Any MRI or CT Scan report within two years.
5.
$100 reservation fee required from patient. Payable by cash, money order or cashier’s check (refundable on first visit).
6.
New patient consultation packet. Must be completed, signed and returned before appointment is scheduled. It contains:
a) Patient information sheet
b) Prescription renewal policy
c) Consent for chronic opioid therapy
d) Agreement for long-term opioid use
e) Patient account terms
f) Cancellation policy
g) Photo authorization
h) Waiver of liability
i) Psychiatric treatment policy
j) Assessment of addiction liability
k) Hamilton depression rating scale
l) Pain and medical history
Checklist for psychiatric/pain management
Consultation/New Patient Referral: 1.
$100 reservation fee from patient. Payable by cash, money order or cashier’s check (refundable on first visit)
2.
New patient packet. Must be completed, signed and returned before an appointment is scheduled. Exception: Pain and medical history not required for psychiatric visit.
The packet contains:
a) Patient information sheet
b) Prescription renewal policy
c) Consent for chronic opioid therapy
d) Agreement for long-term opioid use
e) Patient account terms
f) Cancellation policy
g) Photo authorization
h) Waiver of liability
i) Psychiatric treatment policy
j) Assessment of addiction liability
k) Hamilton depression rating scale
