Southeast Pain Care Contact Form

If you are interested in scheduling an appointment at one of our locations you can fill out the contact form below and we will have one of our scheduling coordinators contact you about scheduling an appointment.

Physician Referral Form

If you are a physician, or from a physician’s office, and are interested in referring a patient to Southeast pain Care please fill out the form below. Please make sure to select the pain management clinic your patient wishes to visit as well as the pain management physician you would like your patient to see. Once the form has been sent a Southeast Pain Care representative will notify you when your patient’s appointment has been scheduled.

Today's Date:

Patient Information

Reason for Referral*:

Evaluation & Treatment Evaluation Only
Block Only SCS Trial

 

Patients Name*:

 

DOB:

 

Patient Address*:

 

City, State, Zip:

 

Home Phone*:

 

Work Phone:

 

Cell Phone:

 

Insurance Carrier*:

 

Type of Appointment*:
First Available or
After Work Hours (CMC - Main and CMC - Huntersville locations only) or
Request SEPC Physician:

 

Location:
Select from dropdown Blue Ridge HealthCare Hampton Roads Hickory CMC-Huntersville Kings Mountain Hospital CMC-Main Museum Medical Plaza Piedmont Medical Center CMC-Pineville Stanly Regional CMC-Union CMC-University

 

Patient Pain Conditions*

Arthritis

Back

Neck

Headache & Migraines

CRPS (RSD)

Neuropathic Pain

Spinal Cord Injury

Cancer Pain

Myofascial Syndrome

Extremity Pain

Failed Back Surgery

Work Injury

Post Surgical Pain

Shingles

Fibromyalgia

Sciatica

Joint Pain

Other

Include Diagnosis:

 

Physician Information

Practice:

 

Physician's Name*:

 

Phone Number:

 

Fax Number:

 

Contact Person:

 

Notes Included*:

Yes    No

Notes to Follow*:

Yes    No

Send your attachment:

 

  

 

After hitting submit if you are not redirected to the "Thank You" page, please verify that all required fields are complete and resubmit. Thank you.

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