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.