Patient Forms

NEW PATIENT FORMS

Save time at your first appointment by printing out your new patient paperwork and filling it out at home. This paperwork will help us get a better understanding of your pain, your health history, and any factors that may affect your treatment. Please bring your paperwork, photo ID, and insurance card to your appointment.

TELEMEDICINE WAIVER

Please fill out this telemedicine waiver and return to our office.

CURRENT PATIENT FORMS

If you were previously a patient at The Center for Pain Management but have not been seen in the last 6 months – 3 years, please fill out this paperwork. Please also fill out the Opioid Agreement.

PATIENT REFERRAL FORMS

If you are a healthcare professional or clinician (such as a representative from a physician practice, insurance provider, employer, or a health plan case manager) referring a new patient for treatment, please fill out the relevant Patient Referral Forms and fax them to (317) 706-3417. (Center for Pain Management does not require new patients to have a referral; however, some insurance plans may).