Physician Referral

After filling out the information below, please email the following materials to info@seattlepainrelief.com

History and physical or recent progress notes
Recent imaging, if applicable

Patient's Name(Required)

First Last

Patient's Date of Birth

Patient's Phone Number(Required)

Chief Complaint / Diagnosis(Required)

Patient's Insurance Company

Please select other if the insurance is not listed or self pay.

Other Insurance

Referring Physician's Name(Required)

Referring Physician's Office Number

Treatment Options

Back Pain Treatments

Caudal Steroid Injection

Cervical Steroid Injection

Disc Denervation

Dorsal Root Ganglion Stimulation

Epidural Steroid Injection

Facet Injections

Ganglion Impar Block

Genicular Nerve Block

Hip Injections

Intercostal Nerve Block

Knee Joint Injections

Medial Branch Blocks

Occipital Nerve Block

Peripheral Nerve Stimulation

Piriformis Injection

Radiofrequency Ablation

Sacroiliac Joint Injections

Shoulder Injections

Sphenopalatine Ganglion Block

Spinal Cord Stimulator Implants

Stellate Ganglion Block

Supartz Series

Superior Hypogastric Plexus Block

Sympathetic Block

Trigger Point Injections

Trochanteric Bursa Injection

Whiplash and Back Injuries from Car Accidents

Evaluation Only

Name

This field is for validation purposes and should be left unchanged.

35002 Pacific Highway South
Suite A-105
Federal Way, WA 98003

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Pain Conditions
Services
About
Referrals
- Physician Referral
- Attorney Referral
Contact

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Hours: Mon-Fri 8:00AM - 6:00PM