* Indicates a Required Field


Our goal is to aid in stabilizing your patient by recommending or providing appropriate treatment with the expectation that long-term care (including medications) will be continued by the primary care physician. We will remain available for consultation as needed but we do not provide long-term medication management for patients.

Patients will be evaluated by our interdisciplinary team as dictated by their needs and treatment recommendations developed.

  • Patients that are evaluated on a consultation basis will have recommendations for future treatment made to you and the patient.
  • Patients who continue treatment at the Pain Management Center will have a treatment planning visit to discuss the recommendations followed by initiation of indicated therapies, procedures and medications.

Opioids are not prescribed during our evaluation phase or for patients seen on a consultation basis.

Patients referred for a procedure only will be evaluated by the pain physician for consideration of interventional options. If full interdisciplinary evaluation is warranted this will be arranged in the future.

Are you willing to accept the patient back into your practice after completion of the program including prescribing medications?

Yes    No *


Fast Track?  

Yes    No *

Reason for Consultation*
Need assist with pain diagnosis
Confirmation of continuing stable opioid dose
Recommendations for adjustments of opioid dose
Seek advice on opioid rotation
Request for taper plan to decrease opioid dose
Aberrant behavior, confirmation to discontinue opioids
Seek advice regarding adjuvant analgesics
Seek advice regarding non-pharmacologic strategies
Other
Patient Demographics
Referring Physician Information
Insurance Information
Workers Compensation Corporation
Primary Care Physician (if different from referring physician)

To expedite this process, please fax the following to 801-585-3274:

  • Last three clinic notes and initial history and physical
  • Spine procedures, a copy of any recent MR/CT reports.

You may also mail the information to;
REQUEST FOR CONSULTATION
615 Arapeen Way, Suite 100
Salt Lake City, UT. 84108

For questions please call or leave a message at 801-581-2988.
The request is incomplete until ALL information is received.