Forms

New Patient

Don’t worry. We create a medical record file for you on your first visit. We strongly recommend that you bring reports of any X-rays, MRI’s, CT scans, or Lab tests that you have. Also, bring a report of your medical expenses from your pharmacy or pharmacies listing all the medications that you are currently taking, along with medical records or consultation notes from your current or past pain management doctor, primary care physician, ER doctor, or any other specialist you have received treatment from. You will not be able to see a doctor without these reports. If you have never been to pain management before, the doctor will start your treatment by ordering some diagnostic tests. Please download these forms, print them out, answer completely to the best if your knowledge and put mail them to us, or bring them to your appointment.

Registration Form

Consent Agreement Form

PIP/Insurance Information

Assignment Of Benefits

Health Information Release Form

Patient History Form

Out Patient Services Form

Patient Authorization Genesis

Opioids and Addiction Information

Returning Patient

Please, take the time to fill out the below forms, explaining your previous visit and related medical conditions.

Follow Up Visit Form

Evaluation Temple Terrace

Evaluation W. Waters Ave.

Opioids and Addiction Information