ASC Forms - Patient Referral Form | River Cities Interventional Pain Specialists

ASC Forms

Referring Providers

Park Plaza Surgical Specialists strives to keep open and clear communication with its referring physician community.

If you would like to refer a patient for interventional pain care you will find our referral form below.

Scheduling Process

When referring a patient, the information we need is:

  1. Park Plaza Surgical Specialists Referral Form (below)
  2. Patient Demographics
  3. History and Physical Notes
  4. Medication Summary
  5. Diagnostic Imaging (MRI, CT, X-Ray)
  6. Fax to 318-703-2645