Forms

New Patient and Consultation Packet

Complete this packet and bring it with you to your scheduled appointment. Please review all information closely and complete all requested fields that are applicable.

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Procedure Instructions

Please review these before and after instructions prior to your procedure.

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Medical Records Request Form

Please fill out this form to authorize the release of medical information from your physician to Centers for Pain Management.

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Medical Records Release Form

Please fill out this form to authorize the release of information or documents from Centers for Pain Management to a physician/facility for specific medical purposes or diagnosis.

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Disabled Person's Parking Affidavit

Patients should fill out the top portion of this form and bring to Centers for Pain Management for physician's signature and notarization. There is a $15 fee for this service. Once completed you will need to return the form to the DMV for completion.

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Referring Physician's Form

Physicians who are referring patients to the Centers for Pain Management must complete this form and are required to send an updated medication list, x-ray and MRI reports, previous procedure records/notes, copy of last 3 office notes and pertinent lab results.

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Disclosure of Information

Please sign this form to authorize who may view your medical information.

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Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully and sign.

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Notice of Information Practices

This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review carefully.

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Pain Diary

In order for the physician to make an informed decision concerning your course of treatment, it is important you keep an accurate, objective log of your pain. After your procedure, please complete the pain diary and bring to your next appointment.

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Download Patient Forms

Patient forms may be downloaded using Adobe Acrobat Reader.

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Please download it for free.

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