Pain Management Center

Department of Anesthesiology

Columbia-Presbyterian Medical Center

622 West 168^th Street

New York, New York 10032-3784

Telephone: (212) 305-7114

Facsimile: (212) 305-8883

Direction: Physicians-please fax forms AND have your patients call the above number to follow up on appointment dates. This office is no longer able to call patients individually for appts.

CHRONIC PAIN SERVICE REFERRAL FORM

I would like the Pain Management Center to evaluate for comprehensive pain management the following patient:

NAME:

ADDRESS:

TELEPHONE:

MRN:

DOB:

PRIMARY CARE PHYSICIAN:

TEL NO: 305-6262 FAX NO: 305-6279 9; Pager: EMAIL:

PAIN DIAGNOSIS & LOCATION:

PAST PAIN MEDICATIONS:

PAST PAIN TREATMENTS (including surgery):

OTHER PMH:

OTHER MEDS:

REFERRING PHYSICIAN:

DATE: SIGNATURE OF REFERRING PHYSICIAN