In addition to completing this form, please upload or fax our office (606.783.7735) any recent office notes that pertain to the reason of your referral.
PLEASE NOTE:
If patient has an intrathecal pump we will not assume management of this device. If the patient has a spinal cord stimulator the implanting provider will need to contact this office directly for us to assume control.
Patient Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Phone Number (Alternate)
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Female
Male
Other
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Referral Details
Primary diagnosis, symptom, or reason requiring pain consult:
*
Is there a prior discharge from a pain management provider?
*
Yes
No
If so, why?
Has patient had six (6) weeks of physical therapy?
*
Yes
No
NOTE:
If patient has not completed at least six (6) weeks of physical therapy please place a referral prior to being seen by this office or provide documentation stating why they cannot undergo physical therapy.
If no, is patient physically able to participate in a physical therapy program?
Are the supporting documents available? Please select all that apply.
Imaging Reports
History & Physical Evaluation for Referring Dx
Up-to-Date Insurance Card & Information
Physical Therapy Documentation (or documentation for why patient is unable to complete formal conservative treatment)
File Upload
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Referring Provider Information
Indicate referring provider's relationship to the patient.
*
PCP
Surgeon
Other
If other, please specify.
Referring Provider's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Notes
Please check below to acknowledge each note.
*
Please instruct patient to bring all medication bottles along with any outside imaging including discs and reports to initial evaluation.
Please make sure the last six (6) weeks of Physical Therapy Documentation has been included with referral.
St. Claire HealthCare will not assume control of intrathecal pump management.
Form Completed By:
*
First Name
Last Name
Date
*
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-
Day
Year
Date
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