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Arizona Pain Specialists
9787 N. 91st Street, Suite 101
Scottsdale, AZ. 85258  
Phone:  480-563-6400
Pain Referral Form
Paul J. Lynch, MD                        Tory L. McJunkin, MD
Patient name:  First, Last
Date of Birth
Patient phone number:
(xxx) xxx-xxxx
Insurance Company
Reason for Referral
Referring Physician Name
Referring Physicican Office
Number
Referring Physician Fax
Who can we thank for this
referral?
Please type yes if you want us
to evaluate and treat this
patient.
What is your Specialty?
Is there a specific procedure
you would like performed?
Pain medicine, pain management, fibromyalgia, Arizona pain, back pain, pain treatment, discography, back pain, neck pain, migraine., headaches, sciatica, muscle pain, Arizona pain center, acupuncture, arthritis, Arizona, Scottsdale, phoenix
Please Fax the following materials to (480) 563-8009:
  1. History and physical or recent progress notes
  2. Recent Imaging, if applicable