Pain Management Center

Fast Track Referral

bold - indicates a required field

Certain pain conditions may need to be seen on an urgent basis. Please mark the appropriate indication or procedure requiring fast track (please choose at least one option below):

Pain Condition:





Specific Spine Injections/Procedures:









Referring Physician

Primary Physician

Contact Person

Patient






Please fax the following information to expedite scheduling:

  • Brief clinical summary that includes diagnosis, pain location, and duration
  • Last clinic note
  • Initial history and physical
  • For spine procedures, a recent copy of the MRI/CT report
  • Insurance information including phone number, insurance subscriber, and policy number (or copy of insurance card)
Please fax information as requested to:
Pain Management Center Scheduling Coordinator - (801) 585-3274
The referral is incomplete until all information is received


For any questions please call or leave a message at (801) 581-2988