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

To schedule an appointment

Call 318-703-2643 or