Text size: [+] Larger  [-] Smaller
Contact the Clinic

Medical Professionals Who Need To Refer A Patient

If you are a physician or medical specialist who needs to refer a patient to our clinic, please call us and we can fax you a copy of our referral form, or you can download a copy below.


Please complete the form with the patient’s information and fax it back to us along with any information about the patient that may be helpful in treating or diagnosing their condition. If possible, please include the results of diagnostic tests, reports from other specialists, and a list of the patient’s medications. Once we receive the form we will contact the patient directly.

How long will the patient have to wait for the first appointment?

It takes about one week to process the paperwork for a referral. We are a very busy clinic and there is always a waiting period. There are many factors, which influence the wait time including patient load and number of doctors currently available to perform treatments. If you call the clinic, we can give you an estimate of the waiting period based upon current conditions.

Patients Seeking A Referral

If you are a patient seeking a consultation please ask your doctor to refer you to the clinic. You can download a referral form, or we can fax a referral form for to you to present to your physician. Your physician may also call our clinic and we will fax them a referral form upon request.


If you do not have a physician in your area due to a doctor shortage, it is possible that you may be accepted without a referral. It is best to get a referral from a physician so we can work with them during the treatment process.

Continue reading › Outgoing Referrals to Other Physicians

This website contains links to third party websites. The views and opinions expressed therein are those of the individual speakers, and do not necessarily represent the views and opinions of the Rothbart Centre For Pain Care or any of its respective affiliates and employees.

Third party websites may make references to medications, medical procedures, and other medical or non-medical information. We cannot verify the accuracy of any information on third party websites. The information on third party websites may be false or harmful. Medical information on our website or any third party website should not be relied upon in lieu of actual medical advice from a real physician. 

If you have any specific medical problems, you should see your physician. Please do not rely upon the general advice on our website or any other website, as a replacement or substitute for actual medical advice from your physician. Please see your physician if you have any medical questions or concerns.

[Close Window]