San Diego Pain Docs

Lars R Newsome, MD | Pain Management Office
4130 La Jolla Village Drive, Suite 300 | La Jolla, CA 92037

Patient Referral Form

Patient Name
Date of Birth
Diagnosis/ICD-9
Patient's Contact Number
Referring Provider Name
Referring Provider Office Number
Treatment/Service Requested (check all that apply)	Pain Management Consult, evaluate and treat Epidural Steroid Injection-Cervical Epidural Steroid Injection-Thoracic Epidural Steroid Injection-Lumbar Selective Nerve Root Block/TFE-Cervical Selective Nerve Root Block/TFE-Thoracic Selective Nerve Root Block/TFE-Lumbar Facet Joint Injection-Cervical Facet Joint Injection-Thoracic Facet Joint Injection-Lumbar Sacroiliac Joint Injection Discography-Cervical Discography-Lumbar Spinal Cord Stimulator Intrathecal Pump Sympathetic Nerve Blocks Intercostal Nerve Blocks Other, please specify below and include level and side if appropriate.