Doctors Pain Clinic

Getting You Back to a Pain-Free Life
888-784-4312

New Patient Referral Form

* Required field


PATIENT INFO:

Patient Name *:
Patient Address *:
Patient City *:
Patient State *:
Patient Zip *:
Date of Birth *:

Social Security Number (no hyphens):
Phone Number (no hyphens): *
Insurance:
Is this a work-related injury? Yes   No
Has the patient been seen in any pain clinic before? Yes   No
If yes, facility name:
Has this patient ever been dismissed by another physician? Yes   No
If yes, physician's name:
Patient's primary care physician: *

REFERRING PHYSICIAN INFO:

Physician Name: *:
Office Contact for This Referral:

Ext:
Email Address: *
Phone Number: (no hyphens) *
Fax Number: (no hyphens)
Address: *
City: *
State: *
Zip Code: *
NPI#: *
Medicaid Billing Number: *
UPIN#:
Select the office location most convenient for your patient: *
Additional Comments:

Reports Needed for Referral for Consultation to Doctors Pain Clinic:

We will call your patient to schedule and appointment as soon as all the information below is received in our office.
Last 2 progress notes:
DX:
Demographic Form:
C-9 for Worker's Compensation:
Medication List:
Previous or recent test reports/results related to the condition (MRI, X-rays, CT scans, EMGs, etc.):
Additional Information:
   

 

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Doctors Pain Clinic

Main Office:
1011 Boardman-Canfield Road
Youngstown, Ohio 44512
Phone: 330-629-2888
Toll Free: 888-784-4312
Fax: 330-629-8940

Howland Office:
Hunter's Square
8740 E. Market St., Suite 2
Warren, OH 44484
Phone: 330-647-6404

 

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