Eastern Utah Physical Medicine and Pain Center - Patient Referral Form

Eastern Utah Physical Medicine and Pain Center – Patient Referral Form Phone: (435) 613-7246 Fax: (435) 613-7247

Patient:______DOB:______

Please send a copy of patient’sinsurance information, demographics, recent progress notes, and diagnostic reports. In order to schedule for a procedure the patient must have a recent imaging study such as MRI or CT myelogram. Please also indicate if the patient is taking any blood thinner medications.

Pain Management:

Diagnosis or presenting problem:______

□Evaluate and treat

□Consultation and recommendation, then return to sending clinic for care

Please make arrangements for your patient if they are currently on any type of narcotics for their pain control, as our physician will not write narcotics until hisevaluation is complete. Completion of evaluation entails initial assessment, drug screen confirmation and any diagnostic testing results heordered to have been received and reviewed by the physician. Narcotics most likely willNOT be written at the first appointment. Once the physician determines medical necessity, he will then write what he deems appropriate for the patient’s condition.

Interventional Procedures:

Lumbar:

□Epidural steroid injection

□Selective nerve root block: Level and side:______

□Facet injection: Level and side:______

□Medial branch blocks with progression to radiofrequency ablation: Level and side______

□SI joint injection: Side______

□Intradiscal steroid injection: Level ______

□Provocative discogram: Level______

Cervical:

□Epidural steroid injection

□Selective nerve root block: Level and side:______

□Facet injection: Level and side:______

□Medial branch blocks with progression to radiofrequency ablation: Level and side______

Thoracic:

□Thoracic epidural steroid injection

□Selective nerve root block: Level and side______

Other EMG/Nerve Conduction Study:

□Lumbar sympathetic block: Side______Suspected Diagnosis:

□Cervical sympathetic block: Side______ Carpal Tunnel Syndrome

□Kyphoplasty: Level ______ Cervical Radiculopathy

□Intra-articular hip injection: Side ______ Lumbar Radiculopathy

□Blood patch (for post dural puncture headache) Peripheral Neuropathy

□Evaluation for spinal cord stimulation Other ______

ReferringPhysician’s Signature:______Date:______