For Referring Providers

If you are a Referring Provider and you would like to provide an opportunity for your patients to receive treatment from a pain specialist who will genuinely strive to either eliminate or lessen their pain issue, then please complete the following Referral Form

To ensure your patient is seen as quickly as possible, please fax the following documents with your referral request:

  • Recent Physician notes
  • Applicable radiology reports (MRI, X-Rays, etc.)
  • Insurance & demographic information

You may also download copies of our referral form to keep on hand in your office. Referral forms should be faxed to 888.771.6735.