Please print, fill out the form completely prior to your visit and bring to your upcoming appointment.
Failure to follow the instructions may cause your procedure to be delayed or cancelled.
If you think you may be pregnant or are trying to get pregnant, you must let the pain clinic staff know immediately. You will be administered a urine pregnancy test prior to any procedure.
Blue Care Network/HMO:
Please request a referral form from your family Physician/PCP for your visit/appointment/procedure.
The referral form needs to be faxed to our clinic (248-929-8930) at least a day before appointment.
Please call our office if you have any questions at 248-929-8165.