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1800 PAIN 00
0399598315
[email protected]
Monday to Friday
08:30 A.M. to 05:00 P.M
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Home
About us
Conditions We Treat
Musculoskeletal Pain
Headaches/Neuralgia
Cancer Pain
Chronic Pain Syndromes
Acute Pain Crisis Management
Patient Information
For Doctors
Referral Templates
Contact us >
Home
About us
Conditions We Treat
Patient Information
For Doctors
Referral Templates
1800 PAIN 00
0399598315
[email protected]
Monday to Friday
08:30 A.M. to 05:00 P.M
Follow us
Click here to setup your social networks
Sign in
Contact us >
Patient Referral
Patient Name
*
Date of birth
Address
Mobile/Landline
Pain and related medical and psychological history:
Please Choose:
Private patient
TAC/Worker compensation (No out of pocket billing)
Neck/Back pain
Limbs/Joint pain
Pain syndromes (widespread pain/Fibromyalgia ,CRPS ,Neuropathic pain)
Visceral pain
Persistent post-surgical pain
Other
Service requested:
Comprehensive pain management
Interventional pain management (Nerve blocks/njections, Radiofrequency, Neuromodulations)
Referrer Name
Provider Number
Phone
Fax
Subject
*
Submit