Forms

New Patient Forms

Call our office, and we can mail a paperwork packet to you.

• Center for Pain Management
  • Click on this link to print your paperwork.
  • Click on this link to submit your paperwork electronically.
  • What you need to know for your first visit.
• Integrated Pain Solutions
  • Click on this link to print your paperwork.
  • Click on this link to submit your paperwork electronically.
  • What you need to know for your first visit.
• Spine Care Specialists
  • Registration Form
  • New Patient Questionnaire
  • Follow Up Form
  • Medication List
  • SCS Privacy Notice & HIPAA

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.

Medical Records Release Form

If you need a healthcare provider to share your records with us, please complete and sign the form and give it to your doctor.

• Center for Pain Management
• Integrated Pain Solutions

Telemedicine Waiver

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