Schedule an Appointment | The Pain Management Clinic

Schedule an Appointment

Patient Info

*Patient Name:

*Date of Birth (Month/Day/Year):

Sex:

*Address:

Male

Female

*City:

*State:

*Zip:

*Phone:

Insurance Info

Patients Name:

Insurance Carrier:

Self Pay:

Policy Name Holder:

Date of Birth:

Member ID:

Group Name:

Group Number:

Insurance Co. Phone:

ext:

Workers Comp Insurance Info

WC Insurance Carrier:

Claim #:

Date of Injury (Month/Day/Year):

Claims Phone:

ext:

Adjuster Name:

Adjuster Phone:

ext:

Adjuster Fax:

Adjuster Email:

Case Manager Name:

Case Manager Phone:

ext:

Services Requested

	Back Injury		2nd Opinion
	Neck Injury		EMG / Nerve Conduction
	Knee Injury		IME
	Shoulder Injury		Evaluate and Treat
	Other

Referral

Referring Physician Name:

Referring Physician Phone:

ext:

Referring Physician Address:

City:

State:

Zip:

Miscellaneous

Comments/Additional Information:

Our Focus

We are a pain management practice, with a focus on managing our patients pain, so they can focus on taking care of their families and lives. Stop your Pain and Start Living Again!

Why The Pain Management Clinic

One on one patient processing
An always Very friendly Staff
A Doctor who listens and cares
See the same Doctor every Visit
Affordable treatment plans
Most Major insurance and Self pay accepted
We treat you like family

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