Get the free Chronic Pain Clinic – Referral Form

This form is used for referring patients to the Chronic Pain Clinic at Jim Pattison Outpatient Care and Surgery Centre, requiring relevant medical reports and personal information for assessment and eligibility.

How to fill out chronic pain clinic referral

How to fill out chronic pain clinic referral

1. Gather patient information: Name, date of birth, contact details, and insurance information.
2. Document the patient's medical history: Include chronic pain conditions, treatments tried, and medications.
3. Record symptoms: Note the intensity, location, and duration of the pain.
4. Complete the referral form: Fill in all required fields accurately.
5. Attach supporting documents: Include previous treatment records and imaging results if applicable.
6. Sign the referral: Ensure the referring physician signs off on the document.
7. Submit the referral: Send it to the chronic pain clinic via fax, email, or physical mail.

Who needs chronic pain clinic referral?

1. Patients experiencing persistent pain lasting more than three months.
2. Individuals whose pain affects daily activities and quality of life.
3. Patients who have not responded to primary care treatment for pain management.
4. People with complex pain conditions requiring specialized evaluation and treatment.

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What is chronic pain clinic referral?

A chronic pain clinic referral is a formal request from a healthcare provider to a specialized clinic that focuses on diagnosing and treating chronic pain conditions.

Who is required to file chronic pain clinic referral?

Typically, healthcare providers such as primary care physicians, specialists, or other medical professionals who assess a patient's chronic pain condition are required to file a chronic pain clinic referral.

How to fill out chronic pain clinic referral?

To fill out a chronic pain clinic referral, start by providing the patient's personal information, medical history, details of the chronic pain condition, relevant diagnostic tests, and any previous treatments that have been tried.

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 offer targeted treatments, interventions, and a multidisciplinary approach to managing their chronic pain.

What information must be reported on chronic pain clinic referral?

The information that must be reported on a chronic pain clinic referral includes the patient's demographics, diagnosis, medical history, the nature of the pain, previous treatments attempted, and any relevant imaging or test results.