Pain Management Center

Request for Consultation

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Thank you for your request for consultation for pain management services. We are an interdisciplinary clinic providing evaluation and, when appropriate, treatment by pain management physicians, physical therapists, psychologists and pharmacologists. We are unable to provide long-term medication management, but work to stabilize the patient with the expectation that long-term care will be continued by the primary care physician. We will remain available for consultation as needed. Please note:

  • We do not provide any therapies or prescriptions on the day of the evaluation.
  • Patients will be evaluated on a consultation basis and recommendations will be made to you and the patient.
  • If the patient is appropriate for treatment here, treatment will begin on the day of their treatment plan visit (usually 1-2 weeks following the evaluation).
  • Prior to scheduling an evaluation we require the following information:
    1. Relevant medical records pertaining to diagnosis and previous treatment of the patient's pain problem. This should include a summary letter.
    2. Provide insurance information and a current medication list.

If, upon review, it is determined that the patient is not appropriate for the consultation here, we will notify you the reason for denial by phone.

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


If no, please provide information for PCP below as this is required for consultation.

Please provide us with all of the following information:

Patient Demographics












Referring Physician Information










Primary Care Physician (if different from referring physician)









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

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