Patient Referral

Always accepting new patients.

Help your patients achieve better living through an individualized, multi-modal pain approach. Refer a patient by filling out the form below.

Refer a Patient

Referring Provider*
Clinic Name*
Clinic Phone*
Patient Information
Name*
First Last
Phone*
DOB*
Month
Day
Year
Cell Phone
Insurance Carrier*
Type of Injection Requested*
Type of Pain Symptoms*
Clinic Notes / Comments
Comments
This field is for validation purposes and should be left unchanged.

Requests for appointments may be made by a provider referral.

To make an appointment for your patient, you may do one of the following:

Call our scheduling department at 218.894.7730
Fax a referral form or your order to 218.894.7734. Please include any clinic notes about pain and any imaging regarding the pain (MRI/CT/XRAYS)
Complete and submit the information on this secure referral request.

Questions? Call 218.894.7730

If you are a provider and would like to speak with one of our providers by phone, please contact Jody at our main number above and we’ll return your phone call.

Patient Referral

Refer a Patient

Patient Information