Phone# 708-344-1234
FAX # 800-525-1686

    Dear Physician,

    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.
    We are able to initiate accepting patient by
    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
    your patient.

    Dear Patient,

    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.

  • Patient 's Pain Questionnaire  Form

       pain  Questionnaire form       

  • Notice of Privacy Practices (Please read,
    then print and sign last page):

       HIPAA Form

  • Demography form:

Demography form