Health Care Home Pain Management Center Request for Consultation at the Pain Management Center Call 801-581-7246 or Request an Appointment Refer a Patient You must have JavaScript enabled to use this form. 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? Yes No If No, Why?: Fast Track? Yes No If No, Why?: Reason For Consultation Reason For Consultation * OtherNeed assist with pain diagnosisConfirmation of continuing stable opioid doseRecommendations for adjustments of opioid doseSeek advice on opioid rotationRequest for taper plan to decrease an opioid doseAberrant behavior, confirmation to do discontinue opioidsSeek advice regarding adjuvant analgesics Seek advice regarding non-pharmacologic strategiesIf Other, Please Explain If Other, Please Explain Patient Demographics Full Name: * Patient's Date Of Birth (MM/DD/YYYY): * If Child, Name Of Parent: basic info Address (Line 1): Address (Line 2): City: * State: * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code: * Phone Number (000-000-0000): * Email Address: Referring Physician Information Full Name: * Specialty: * Phone Number (000-000-0000): * Fax Number (000-000-0000): * Insurance Information Insurance Company: * Phone Number (000-000-0000): * Policy Number: * Authorization Phone Number (000-000-0000): Workers Compensation Corporation Adjuster's First Name: Adjuster's Last Name: Date Of Injury: Claim Number: Adjuster's Phone Number (000-000-0000): Primary Care Physician (if different from referring physician) First Name: Last Name: Last Name Phone Number (000-000-0000): Fax Number (000-000-0000): Leave this field blank