ASC Forms - Patient Referral Form | River Cities Interventional Pain Specialists
[email protected]  318-797-5848
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ASC Forms

Patient Rights and Responsibilities
Pre-Procedure Patient Information
Post Procedure Patient Information
Procedure Consent
Discharge Instructions
Hourly Pain Diary

Contact Details

Address:

River Cities Interventional Pain Specialists
8731 Park Plaza Drive
Shreveport, LA 71105

Email:

[email protected]

Phone Number:

318-797-5848

Fax Number:

318-797-5844

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
Injection Only Referral Form