The Referral Form Bellingham Spine Pain Specialists

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Referral to Way Yin, MD
for Management of Chronic Pain
Please circle
reason for referral
Date: _________________________
Referring Physician or Healthcare Professional: ______________________
Cervicogenic Headache
Patient name: _________________________________________________
Cluster Headache
Date of Birth: ___________________
Neck Pain
Comments:
Whiplash Injury
Cervical Disc Pain
Cervical Radicular Pain
Thoracic Pain
(for referring admin staff)
Thoracic Radicular Pain
Insurance:
Post-Thoracotomy Pain
☐ Regence Blue Shield!
☐ HMA
☐ L & I
☐ Premera Blue Cross
☐ First Choice
☐ Group Health
Low Back Pain
☐ Blue Cross/Blue Shield
☐ Aetna
☐ Medicare
☐ Other:
Coccydynia (tailbone pain)
For work injuries, please include claim number and claim manager name:
Lumbar Disc Pain
Lumbar Radicular Pain (sciatica)
For Auto or Personal Injury, please include auto insurance and attorney name:
Sacroiliac Joint Pain
Complex Regional Pain Syndrome
(CRPS)
Please forward patient demographic and insurance information as well as any recent
pertinent clinical records you feel are helpful. Dr. Yin will gladly review information
Trigeminal Neuralgia
provided, and our office staff will directly contact your patient to schedule a
consultation.
Sphenopalatine Neuralgia
Dr. Yin will also personally keep you up-to-date regarding our care of your patient.
Vertebral Compression Fracture
THANK YOU FOR YOUR REFERRAL!
Visceral Pain
By Mail:
By Fax: (360) 527-8115
Bellingham Spine Pain Specialists
Myofacial Pain
(if more than 25 pages, please mail)
Way Yin, MD
By email:
2075 Barkley Blvd.
Other:
Bellingham, WA 98226
2075 Barkley Blvd., Bellingham, WA 98226
phone: 360
527
8111
fax: 360
527
8115
・
・
・
・

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