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  • Pain Management New Patient Registration Form

    v 06/2023 NPP
  • Demographics:


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  • Current Medical:

    Please discuss current medical problems in as much detail as possible.

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  • Pain Symptoms

    Please be as detailed as possible and include pain, numbness, weakness, tingling, hot/cold, etc.
  • Known Medical Problems and Diagnoses

    Please tell us all your known medical conditions (current and past).
  • Tobacco, Alcohol, Substance Abuse History

    Please note your answers will become a PERMANENT record on your chart.
  • Patient Responsibilities

    Terms and Conditions
  • Records and Insurance Informaton:

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  • Upload a Valid Identification Card

    Drivers License, ID Card, Passport
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  • Payment Information

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  • NOTICE: This form is intended to be reviewed by our doctors,  a permanent addition to your medical record. Once you click "Submit", this action cannot be reversed. For any questions or concerns before you submit this form, please email "info@paincaretx.com"

     

  • PLEASE CLICK SUBMIT

    Please click "Submit" to send the document to our team in a HIPAA Compliant Manner. A copy will be sent automatically to the email address you have indicated on the form. If you do NOT receive a copy, then its likely that the form did not submit correctly. Please let us know if you have any issues or concerns. You will be redirected to a form that allows you to request medical records from any other doctors.
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