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Request for Consultation at the Pain Management Center

Our goal is to aid in stabilizing your patient by recommending or providing appropriate treatment with the expectation that long-term care (including medications) will be continued by the primary care physician. We will remain available for consultation as needed but we do not provide long-term medication management for patients.

Patients will be evaluated by our interdisciplinary team as dictated by their needs and treatment recommendations developed.

  • Patients that are evaluated on a consultation basis will have recommendations for future treatment made to you and the patient.
  • Patients who continue treatment at the Pain Management Center will have a treatment planning visit to discuss the recommendations followed by initiation of indicated therapies, procedures and medications.

Opioids are not prescribed during our evaluation phase or for patients seen on a consultation basis.

Patients referred for a procedure only will be evaluated by the pain physician for consideration of interventional options. If full interdisciplinary evaluation is warranted this will be arranged in the future.

Are You Willing To Accept The Patient Back Into Your Practice After Completion Of The Program Including Prescribing Medications?
Fast Track?
Reason For Consultation

Patient Demographics

basic info

Referring Physician Information

Insurance Information

Workers Compensation Corporation

Primary Care Physician (if different from referring physician)