Patient Forms

NEW PATIENT FORMS

Completing the new patient paperwork prior to your first visit with us is extremely important. We understand that these forms will take time to complete, but they will provide us with the information we need to gain an understanding of your condition and individualize a plan of care for you. We offer several options for completing this paperwork:

  • Call our office, and we can mail a paperwork packet to you.
  • Click on this link to print your paperwork.
  • Click on this link to submit your paperwork electronically.

Please remember to bring your photo ID and insurance card to your appointment. We look forward to meeting you.

TELEMEDICINE WAIVER

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

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).