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Schedule a Center for Pain Management Appointment Online

Please correct the following:

Ordering Physician must be entered.
Ordering Physician Phone must be entered.
First Name must be entered.
Middle Name must be entered.
Last Name must be entered.
DOB must be entered.
Patient's Phone must be entered.
Patient's Email must be entered.
Relevant Diagnosis must be entered.
Symptoms must be entered.
Procedure Location must be entered.
Preferred Day must be selected.
Preferred Time must be selected.

I am a:

Patient Office Staff

*Ordering Physician:

*Ordering Physician Phone:

You must bring the order signed by your physician to your Center for Pain Management appointment

*Patient's First Name:

*Patient's Middle Name:

*Patient's Last Name:

*Birthdate:

*Patient's Phone:

*Patient's Email:

Address:

*Relevant Diagnosis: The most specific known diagnosis relevant to this exam.

*Symptoms: Any symptoms you are experiencing related to this exam

Screening Questions

Is the patient on blood thinners of any type? Consider holding blood thinners for 3-5 days, except NSAIDs.

Yes No

Does the patient have a contrast allergy? Premedication is recommended.

Yes No

Is the patient diabetic? Anticipate a possible increase in blood glucose.

Yes No

Is the patient wheelchair dependent?

Yes No

Is the patient on contact precautions? (i.e for MRSE or VRE)

Yes No

Please list any previous spine surgery, including type and spinal level: For example: Fusion L3L5.

Procedure

Procedure Type: You may select multiple procedures, as appropriate.

Lumbar Epidural Steroid Injection Sacroiliac Joint Injection Lumbar Discogram Selective Nerve Root Block & Steroid Injection Facet Block with Steroid Injection Arthrogram/Joint Injection Facet Rhizotomy (RF Ablation) Bursal Injection Trigger Point Injection

Comment/Procedure Request:

*Procedure Location. Please specify side and level, as appropriate: For example: Right L4 or Left L4/5 or Both Wrists

Schedule

*Preferred Day:

*Preferred Time:

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I understand and wish to continue

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