Physicians Pain Management Center Referral Form
Patient's Name
Address
City
State
Zip Code
Daytime Phone
Evening Phone
Email
Referring Physician
Referring Physician's Email
Referring Physician's Phone
Referring Physician's Fax
Primary Care Physician
Additional Information


You May Fax the following Information to: 508-823-6127

  1. Patient's insurance carrier information
    i. Primary Insurance
    ii. Secondary Insurance
  2. Is the patient Workman's Compensation?
  3. Patient's latest Medical history, MRI reports, X-Ray reports, EMG, and any other pertinent information

Security of Personal Information

You should understand that Physicians Pain Management Center cannot absolutely guarantee the confidentiality or security of information your provide in the referral form.

We will use your referral form to begin arranging for care where appropriate and necessary. The information you provide will be kept private in accordance with our confidentiality policies, and will be seen by a limited number of authorized individuals as necessary. If you need to change this information, please contact our Physicians Pain Management Center at 508-824-0035. We may contact you if we need to verify or obtain further information. You should understand that this referral form does not establish a doctor-patient relationship; you may become a patient if you come to our center for treatment. At that point, this form will become part of your medical record.

RF LESIONING
DISCOGRAPHY
EPIDURAL
LUMBAR FACET JOINT
SYMPATHETIC BLOCK
STELLATE GANGLION
THORACIC FACET
VERTEBROPLASTY
PROLOTHERAPY