Referring Physicians

Thank you for your interest in The Pain Institute, an outpatient treatment facility serving the northern Kentucky and southern Indiana areas. We welcome referrals from the medical community, and hope to serve as a treatment resource for your patients who suffer acute or chronic pain.

Referring Insurance Guidelines

New Patient Forms

Complete New Patient Packet online and EMAIL or DOWNLOAD and print the new patient packet, then complete and bring them to your appointment to save time during check-in.

New Patient Packet

PATIENT REFERRAL FORM

PATIENT REFERRAL FORM

Complete New Patient Packet online and EMAIL or DOWNLOAD and print the new patient packet, then complete and bring them to your appointment to save time during check-in.

Patient Information

**If patient has been seen within the last 5 years by any other Pain Management Provider we must receive these records for review before an appointment can be made.

Referring Physician:

Please fax this form along with: face sheet, including social security no. and all insurance,
most recent office note, imaging and P.T. reports to 502-429-5913.
For questions, please call 502-292-5566

All physicians are board certified in Anesthesiology and Pain Management.
Nerve Blocks/ Injections/ Spinal Cord Stimulators/ Radiofrequency