Get the free surrey pain clinic referral form

Chronic Pain Clinic Referral Form JPO CSC Fax: (604×582-4591 pH: (604×582-4587 Form ID: Patient Name: Page: 1 of 2 Rev: April 2015 New Patient Re-Referral Surname Given Name Middle Date of Referral:

How to fill out surrey pain clinic referral

1. To fill out a chronic pain clinic referral, begin by obtaining the referral form from your healthcare provider. This form may be available online, at the clinic, or through your doctor's office.
2. Review the referral form carefully, ensuring that you understand all the required information and sections that need to be completed. This may include personal details, medical history, current medications, and the reason for the referral.
3. Fill in your personal information, such as your name, address, contact number, and any relevant identification numbers or healthcare numbers.
4. Provide detailed information about your chronic pain condition. Include the duration of your pain, its intensity, any triggering factors, and how it affects your daily life and activities. It is essential to be as specific and accurate as possible in describing your symptoms.
5. Include a comprehensive medical history, including any past surgeries, significant illnesses, or chronic conditions you may have. If you have previously tried any treatments or therapies for your pain, mention them in this section.
6. Provide a list of all current medications you are taking, including prescription drugs, over-the-counter medications, and any supplements or herbal remedies. Include the dosage and frequency of each medication.
7. If your healthcare provider has requested any specific tests or documentation to be included with the referral, make sure to attach them to the form. This may include recent imaging scans, laboratory results, or specialist reports that are relevant to your chronic pain condition.
8. Before submitting the referral form, double-check all the information you have provided to ensure its accuracy and completeness. If you have any doubts or questions, consult with your healthcare provider or their staff for guidance.

Who needs chronic pain clinic referral?

1. Individuals who have been experiencing chronic pain for an extended period may need a chronic pain clinic referral. Chronic pain is generally defined as pain that lasts for three months or longer.
2. Patients whose pain significantly impacts their quality of life, limiting their ability to perform daily activities, work, or engage in social interactions, may require a referral to a chronic pain clinic.
3. People who have tried various treatments and therapies without success may benefit from a chronic pain clinic referral. These clinics often offer a multidisciplinary approach to pain management, involving specialists from different fields to develop an individualized treatment plan.

Remember, it is always best to consult with your healthcare provider for specific guidance regarding whether a chronic pain clinic referral is appropriate for your situation.

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What is chronic pain clinic referral?

A chronic pain clinic referral is a formal request made by a healthcare provider for a patient to receive specialized treatment and management for persistent pain that lasts longer than the usual recovery time.

Who is required to file chronic pain clinic referral?

Typically, a chronic pain clinic referral must be filed by a primary care physician or any other healthcare provider involved in the patient's treatment who recognizes the need for specialized pain management.

How to fill out chronic pain clinic referral?

To fill out a chronic pain clinic referral, the referring healthcare provider should complete a referral form with patient demographics, a summary of the patient's medical history, the reason for referral, any previous treatments tried, and relevant clinical findings.

What is the purpose of chronic pain clinic referral?

The purpose of a chronic pain clinic referral is to connect patients with specialized care that can provide comprehensive pain management solutions, including medical, therapeutic, and psychological interventions.

What information must be reported on chronic pain clinic referral?

A chronic pain clinic referral must include patient identification details, a detailed pain history, prior treatments, current medications, any relevant diagnostic imaging or tests, and specific questions or concerns that the specialist should address.