Tri-County Pain Consultants appreciates the referral of your patient with Pain. We want you to know that we intend to work with you and your patient together in finding relief for their Pain. We will do everything possible to make sure the lines of communication are open and clear regarding the treatment and progress of your patient. If you would like to refer a patient to Tri-County Pain Consultants you have a few options.
- You can call (800) 319-3118 and a scheduler will set your patient up at the clinic closest to their home or work unless otherwise requested by the referring office.
- You can fill out the form below and give us a few pieces of information and we will call the patient to set up the appointment for you and call you back to let you know the date the appointment is scheduled, for your records.*
- If you prefer to utilize our Fax Referral, you may fax your request to (800) 940-9601 or contact Carmen Walcott. We will personally drop the forms off for you and answer any questions you may have about the process. This form is the same format as our online referral form except it is faxed to (800) 940-9601. If you like you may also fill out the form below, print, and fax it over to us at (800) 940-9601.*
Online Patient Referral Form
Fast Track Scheduling
Phone: (800) 319-3118 Fax: (800) 940-9601 Email: firstname.lastname@example.org
Additional med recs can be emailed to address above or faxed to (248) 735-7340, please do not fax referral requests to this number. All referral requests should be faxed to (800) 940-9601.
To print a copy for your records, fill out then hit File > Print, from the File Menu before you select ‘Submit this Form’.
Please complete this form and click ‘submit by email’ above. Our scheduling department will call the patient to set up appointment and then call you to let you know appointment has been set. Red asterisk indicates required information. Thank you for the referral.