New Patient Packet
Cancer Referral Form
Compression Fracture Form
Referral Form

Please download, print, fill out and fax the appropriate patient referral form along with the following documentation to our office at
812.477.7240 or 888.531.9990

  • Patient demographics and Insurance Information
  • Related office notes from the past 6 months – 1 year
  • MRI/CT/X-ray reports or pertinent lab work
  • Medication List
  • Any previous pain clinic records

We will assign them a physician or they can request a specific provider and will be contacted to set up an appointment.

If the patient has had recent and pertinent x-rays or MRIs, please remind him/her to bring the films or disk to the consultation visit.

If there are any issues relevant to the scheduling, please feel free to contact

Lindsey 812-477-7246 ext 1043 or 1072.