Patient Registration Form

Known Medical Problems and Diagnoses

Please tell us all your known medical conditions (current and past).
Past Medical History: *
Please list all your known medical problems (Heart, Lung, Kidney, etc)
Past Surgical History: *
Please list all prior surgeries and Year performed. Type NONE if no surgeries.

Records and Insurance Informaton:
Please upload any prior records here.

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Payment Information
Please upload your insurance card here

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Please let us know in an email if you have alternate payment arrangements. Paincare@paincaretx.com Cancel of
Please provide your Signature

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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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Pain Management New Patient Registration Form