PATIENT REFERRAL FORM
Central Scheduling Information
office: (469)778-EPIC(3742)
Fax: (469) 405-EPIC(3742) Email: intake@epicpainandortho.com
Clinic Locations
► Please choose a location.
Clinic Location
Dallas/Uptown 4225 Office Parkway, Suite 200 Dallas, TX 75204
Plano/Frisco 6200 Preston Road, Suite 400 Plano, TX 75024
Fort Worth 6850 Manhattan Blvd, Suite 515 Fort Worth, TX 76120
Patient Information
► Please complete each section
Today's Date:
-
Month
-
Day
Year
Date
Date of Injury (if applicable):
-
Month
-
Day
Year
Date
Patient's Full Name:
First Name
Last Name
Patient's Date of Birth (DOB):
-
Month
-
Day
Year
Date
Gender:
Male
Female
Cell Phone Number:
Format: (000) 000-0000.
Home Phone Number:
Format: (000) 000-0000.
Preferred Method of Contact:
Insurance:
Policy Number:
Referring Providers Information
Please complete each section.
Physician's Name:
Clinic or Facility Name:
Email:
example@example.com
Clinic Phone Number:
Format: (000) 000-0000.
Fax Number:
Format: (000) 000-0000.
Reason for Referral
► Please specify the body part affected.
Interventional Pain Management
Hand/Upper Extremity
Knee
Shoulder
Neck
Hip
Mid-Back
Elbow
Low Back
Foot/Ankle
Other
Diagnosis/Symptoms:
Orthopedic/Spine Consultation
Hand/Upper Extremity
Knee
Shoulder
Neck
Hip
Mid-Back
Elbow
Low Back
Foot/Ankle
Other
Diagnosis/Symptoms:
Neurosurgery
Radiculopathy
Herniated Disc
Spine Surgery Consultation
Other
Diagnosis/Symptoms:
Special Comments or Additional Information
Please send demographics and office notes with your referral.
If patient had imaging, pleaserequestpatienttoarrivewithimaging CD (X-Ray/MRI/CT)
Thank you for your referral!
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