Welcome to Interventional Pain Center. For your convenience, we have provided the following forms below so that you can review and/or complete them in the comfort of your home. Please bring the completed forms with you to your appointment.
New Patient Paperwork:
Please print out the forms below for your visit and bring the completed forms to your first appointment.
Financial Policies & Patient Responsibilities:
Please review the policies provided as they are intended to inform you of our expectations regarding payment for services we provide. During your first visit, you will be required to electronically sign in agreement to the policies below.
- Financial Responsibility
- Copay Announcement
- No Show Fee Announcement
- Drug Test Consent
- Informed Consent for Opioid Treatment
- Request a Copy of Your Medical Records
- Authorization for Use and Disclosure of Information
If you would like to obtain a copy of your medical records, please complete the form provided below and submit it
Attn: Medical Records
via Fax (910) 321-7245 OR via Email email@example.com