Advanced Pain Control, Ltd.
    
    
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PHYSICIAN & SURGEON'S REFERRAL

Patient Name*
Birthdate
Phone Number*
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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*

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Records to be sent. (Please include demographic & INS. information.)


*REQUIRED