Telephone:
(336) 538-7180
Toll-Free:
(866) 543-5398
Fax: (336)
538-7739
Francisco A. Naveira, M.D.
Board Certified Pain
Specialist
Patient's Name:
_____________________________________________________________
Patient's Telephone Number:
______________________________
Referring Physician:
_________________________________________________________
Physician's UPIN: ____________
Physician's Telephone
Number:
____________________________
Diagnosis:
__________________________________________________________________
Desired Fast-Track
Procedure:
(Please circle)
1.
Epidural Steroid Injection (Cervical - Thoracic - Lumbar - Caudal)
2.
Selective Nerve Root Block(s).
_______________________________________________
3.
Transforaminal Epidural Steroid Injection
4.
Facet Block
5.
Sacroiliac Joint Injection.
Note: Fast-Track is defined as
a referral for a specific procedure. It will not involve an extensive
evaluation and it will not involve taking over any medications, although
patients may receive some pain medications to help them with any discomfort
from the procedure itself. Once the procedure is done, the patient will be seen
once more, to evaluate the results. Whenever possible, please Fax a copy of any
available MRI, CT scan, X-ray, or EMG/PNCV
reports that may be available. Also Fax the initial patient evaluation and the
last available note.
We kindly Thank
you for the referral.