Advanced Pain Control, Ltd. - Physician Referral Form

PHYSICIAN & SURGEON'S REFERRAL

Patient Name*
Birthdate
Phone Number*	--
Diagnosis
Email Address
	Evaluate and Treat
	Evaluate and Treat For Possible: Lumbar / Thoracic / Cervical Epidural Steroid Injection Sacroiliac Joint Injection Facet Joint Injection Selective Nerve Root Block Specific instructions or other procedure:
	Consult For Possible: Rhizolysis Spinal Cord Stimulator Implantable Medication Pump Percutaneous Decompression Nucleoplasty Discography Other:
	Priority: Please see patient as soon as possible – call 314-729-0707. Call patient to schedule appointment.
	Follow Up: Have patient follow up with referring MD after treatment is completed. Have patient follow up with referring MD after one visit. It is not necessary for patient to follow up with referring MD.
Referring Physician
Office Contact*
Contact Phone Number*	-- Records to be sent. (Please include demographic & INS. information.)
*REQUIRED