Dear Physician, The below links are referral forms which can be downloaded. These documents can either be printed and returned to us by fax or simply edited and fax it to the number 773-894-0320. 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 equiped to care for your patients. Thank you for involving us in the care of your patient.
Out-patient Referral form |
CHICAGO PAIN CLINICS L.L.C |
| Phone# 708-344-1234 |
| FAX # 773-894-0320 |
| FAX # 800-525-1686 |
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |