(904) 264-0770 For Appointments

Premier Spine & Pain Center

Patient Forms

In order to minimize your time away from home, we provide the following forms to download prior to your first visit. Please fill them out and bring the completed paperwork with you to your scheduled appointment.

For Patients

Patient Forms Packet
This packet includes your Patient Registration Information, New Patient History Questionnaire, Patient Consent to Treatment, Financial Policy Agreement, Narcotic Medications Contract, Opioid Risk Assessment, and your Receipt of Privacy Practices Acknowledgement. If you have any questions about these forms, please let us know.

Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Authorization for Release of Protected Health Information
This form authorizes Premier Spine and Pain Center to release protected health information to a patient-specified recipient.

For Physicians

Referral Form for Referring Physicians
If you are a referring physician, please download and fill out this form. Please also send us all relevant notes, medications logs and any radiology reports with the referral.

Getting Ready for Your Appointment

Getting Ready for Your Appointment

At the Premier Spine & Pain Center, we streamline our approach to your care. Download your patient forms, get information about insurance and billing, and get answers to some of our most frequently asked questions.

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Our Pain Management Services

Our Pain Management Services

Our goal is to provide unparalleled patient care. We offer an array of interventional pain management procedures as well as PRP and Regenerative Medicine options. We work with you to reduce or remove your pain to help improve your quality of life.

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Patient Education

Patient Education

We want you to be informed about your pain management treatement and options. Watch videos that explain your pain causes, symptoms and treatment options and start the conversation with your physician today.

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For Appointments
(904) 264-0770

Kingsley Location

1543 Kingsley Avenue
Building 3
Orange Park, FL 32073

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Riverside Location

1045 Riverside Avenue
Suite 110
Jacksonville, FL 32204

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Kennerly Location

6100 Kennerly Road
Suite 101
Jacksonville, FL 32216

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Mcclenny Location

159 North 3rd Street
Macclenny, FL 32063
 

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Starke Location

1548-B South Water Street
Starke, FL 32091
 

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