Self Referral Form

Self Referral Form
Today's Date *

Month Day Year
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Best Time to Call *
Primary Insurance *
Secondary Insurance
Medical Information
Please describe where your pain is located? *
Example: Lower back and radiates into my left leg.
You may also help us visualize the location of your pain by shading the body part in the image provide below.
At our center, we primarily focus on the treatment of spine-related pain, hip, shoulder, knee, and some myofascial pain syndromes. We do not treat migraines or fibromyalgia-related pain at this time.
Are you seeking treatment primarily for migraine or fibromyalgia? *

Yes No
Please explain further if necessary
Have you had a pain management physician in the past? *

Yes No
If YES, please explain the reasoning behind looking for another physician:
Have you taken any pain medications? *

Yes No
If YES, please list the medications you have taken with their dosage.
Have you had any spinal injections? (example: Epidural Steroid Injections, facet injections, etc) *

Yes No
If YES, who was the performing provider?
If YES, when was the last injection date?
Approximate or exact date
What percentage of relief did you experience from your last injection?
Have you had any of the following Imaging Studies? (attaching the report from your imaging studies may expedite your appointment) *

MRI CT Scan X-rays None
If you have had imaging studies please list the study, approximate date it was performed and what facility it was performed at.
Have you tried any of the following, in the past 2 years, for this condition/pain? *

NSAIDs Physical Therapy Chiropractor Pain Medication/Opioids/Narcotics None of the Above
Any history of alcohol or substance abuse? *

Yes No
Who was your last pain management physician?
Have you ever been discharged from a doctor's practice? *

Yes No
Can we check your prescription monitoring program report? *

Yes No
How is your name listed at your pharmacy?
Nickname, Full Name, etc
What kind of treatment are you looking for/expecting?

Injections Medication Management
Who referred you to our practice? Please provide their name, relationship to you, and phone number:
Your physician, Friend, etc. 804-123-4567
Signature *
Date signed *

Month Day Year
Please be advised that incomplete forms will not be processed. Thank you!
Should be Empty:

Self Referral Form

Medical Information