Referral Form For Chronic Pain Management - Gsh Medical printable pdf download

Referral Form For Chronic Pain Management - Gsh Medical

Please fax completed form to: (416)789-2253

Referral Form for Chronic Pain Management

Patient Name:

Address:

Phone Number:

Date of Birth:

OHIP card number:

Referring physician:

Address:

Phone Number:

Fax Number:

Billing number:

Signature:

Date:

Exclusion criteria: Cancer Pain, <18 years old, urgent/emergent cases, addiction, poorly controlled mood disorders, Pain <3 months in

duration.

Reason for Referral:

Previous investigations

Previous treatments (

(please append reports eg. X-

eg. epidural, rhizotomy, nerve block

Ray , U/S, CT scan, MRI, bone scan, EMG) blocks, trigger

points, steroid injections, surgical, other):

Current medications:

practitioner(s)

seen

for

pain

Specialist(s) seen for pain:

management

(eg. physiotherapist, chiropractor, RMT,

psychologist, dietitian):

Incomplete referrals will be returned. Appropriate care will resume once one of our physicians have seen the patient. Some services are

not covered under OHIP (your patient will be informed if required).

Referral Form For Chronic Pain Management - Gsh Medical