Pain Medicine and Pain Management Doctor - referrals

Download Referral Form in Microsoft Word format (352 KB)

Download Referral Form in PDF format (144 KB)

Our office is currently taking REFERRALS from:

• Chiropractors
• Employers
• Massage therapists
• Neurosurgeons
• Nurse case managers
• Occupational medicine physicians/health care providers
• Orthopedic surgeons
• Patient self-referred
• Physical therapists
• Primary care physicians
• Scheduling companies
• Spine surgeons
• Work injury attorneys
• Work comp insurance adjusters

Please Download and fill out a patient referral form so we can have the proper information on file. You may fax the form to our office or call in with the information.

On the referral form, please specify the consultation options:

• Electrodiagnosis (EMG/NCS) and specify the limb(s) and what to rule out
• Evaluate and treat as primary treating physician
• Evaluate and treat as secondary treating physician
• Consult and intervention
• Second opinion (one time consult only)

For epidural injections, acupuncture, and other procedures, Dr. Chan always schedule a consultation visit prior to the procedure(s).