CHICAGO PAIN CLINICS L.L.C
|FAX # 800-525-1686
The below links are forms which can be
downloaded. These documents can either be
printed or edited and returned to us by Fax to
We recognize these forms do take a few
minutes to complete and we recognize your
time is valuable. However, this information
helps us care for your patient. Please send
any additional reports such as EMG/NCS or
imaging studies to our above fax# so that are
best equipped to care for your patients.
having three below document in one package
fax to 773-894-0320:
1) Referral form( filled by referral physician).
2) Imaging study report.( if it was done).
3) Pain questionnaire form ( filled by patient).
For initiating referral Please ask pt to
complete pain questionnaire form
and attached with imaging study report
and refferral form and fax to above Fax
Thank you for involving us in the care of
Out-patient Referral form
In order for Chicago pain clinic to best care
for your needs, the information on these
forms are extremely helpful in our ability to
diagnose and treat your condition. The
below forms can be downloaded and
completed by hand and returned to us by fax
to 773-894-0320. Please return this three
forms and official result of any Image study
(MRI, CT Scan, X-Ray and etc..) in order for
us to contact you for an appointment date.
pain Questionnaire form