Pain Management Center-Procedure-Only Appointment Request Form
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1Phone: (603) 650-6040
Fax: (603) 650-8199
Procedure-Only Appointment Request
Pain Management Center
Patient must have a designated driver or procedure cannot be performed.
Patient name: ____________________________________________________ MRN: ________________________ Date: ___________________
Home phone: ____________________________ Work phone:____________________________ Cell phone: _____________________________
Mailing address: ____________________________________________________________________________________________________________
Insurance: ________________________________________________________ DOB: _________________________ SSN: ___________________
Is this a Worker’s Compensation claim?
No
Yes
Date of injury: ___________________________________________________________
Worker’s Compensation contact: ________________________________________________
WC contact’s phone: _________________________
Are you requesting a specific provider?
No
Yes (specify) _________________________________________________________________
Required Information – please complete the sections below.
Diagnosis: ______________________________________________________________________ Height: ____________ Weight: ____________
Is the patient currently taking antibiotics?
No
Yes (specify) ____________________________________________________________________
Medication: Metformin
No
Yes
Prior Spine Surgeries:
No
Yes (specify) ________________________________________________________________________________
Anticoagulants:
None
Coumadin
Plavix
Fragmin
Lovenox
Other (specify) _______________________________________
Steroid Allergy:
No
Depo-Medrol
Prednisone
Celestone
Solu-Medrol
Other (specify) ______________________________
Anesthetic Allergy:
No
Lidocaine
Novacaine
Bupivacaine
Other (specify) ___________________________________________
MRI/CT (date & area of body): ________________________________________________________________________________________________
Please check box if you believe additional time may be required for this procedure due to:
Age > 90 years
Morbid obesity
Wheelchair
Other _________________________________________
IV sedation needed
Language translator needed
Spinal instrumentation
Please indicate procedure to be scheduled below:
Ultrasound (subject to Pain Physician approval)
Lumbar Epidural Steroid Injection
# _______ & frequency _______
Occipital Nerve Block
Right
Left
Caudal Epidural Steroid Injection
Stellate Ganglion Block
Cervical Epidural Steroid Injection # _______ & frequency _______
Lumbar Med. Branch/Facet Block
Right
Left
Level(s)_____
Thoracic Epidural Steroid Injection
Cervical Medial Branch Block
Right
Left
Transforaminal Injection
Right
Left
Level(s) ______
***C3 and below only***
*MRI/CT REQUIRED FOR ALL OF THE ABOVE INJECTIONS*
Thoracic Medial Branch Block
Right
Left
Select. Nerve Root Block
Thoracic
Lumbar
Sacral
Lumbar Sympathetic Block
Right
Left
Right
Left
Level(s) ______
Radiofrequency
Cervical
Thoracic
Lumbar/Sacral
SI Joint
SI Joint Injection
Right
Left
Right
Left
Trigger Point Injection (Piriformis)
***
Radiofrequency scheduled AFTER a successful block has been
Other: ___________________________________________________
performed at the DHMC Pain Clinic
***
If patient information including medications, x-rays, physical exam, symptoms, and allergies is in CIS, skip section A and proceed to section B.
A. Pertinent symptoms: _______________________________________________________________________________________________________
Pertinent past medical history: ______________________________________________________________________________________________
Pertinent PE findings: ______________________________________________________________________________________________________
MRI/CT/Myelogram results: ________________________________________________________________________________________________
If scheduled: Test: ____________________________ Date scheduled: ____________________ Facility: ____________________________
Allergies/adverse drug reactions: ___________________________________________________________________________________________
B. Referring provider: _________________________________________________________________ Office #: ___________________________
Contact person: _____________________________________________________________________ Fax #: _____________________________
Please notify us of the appointment:
No
Yes
C. Patient follow-up instructions: Follow up with Referring Provider in __________ week(s) post __________ number of injections.
One Medical Center Drive | Lebanon, NH 03756 |
Rev. 11
-30-10
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