CONSULTATION REQUEST
S. Kyle Young, M.D.
Nicolaus Winters, M.D.
Pain Management/Anesthesiology
Please complete the following and fax to 812-476-7117
Or e-mail to info@evansvillepainmd.com
◊ Send records pertinent to consult along with this form:
 Most recent office notes with medical history and updated medication list
 All X-Ray, CT, MRI reports (or where to get reports)
◊ Send copy of insurance card (front and back)
Referring Physician ____________________________________ Telephone.______________________
Contact Name from Referring office: _________________________ position: ______________________
Patient Name ________________________________________________________________________
Date of Birth ______________ Social Security #: ______________________ Marital Status __________
Home Phone ___________________ Work ____________________ Cell ________________________
Occupation _________________________________ Employer _________________________________
Insurance ___________________________________________________________________________
REFERRAL FOR:
Diagnosis/Indication ___________________________________________________________________
SERVICE REQUESTED:
□ Consultation/Evaluation (with a written report back to referring provider)
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□
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Ongoing Medication Management for Chronic Pain
Injection; _________________________________________________________________________
Other ____________________________________________________________________________
Has patient been seen by a previous pain management provider?
□ Yes
□ No
If yes, why is the patient no longer seeing that provider? _______________________________________
____________________________________________________________________________________
FAILED MEDICATIONS:
□ Mobic
□ Lortab/Hydrocodone
□
□
Naproxen
□
□ Percocet/Oxycodone □
□ MS Contin
□
Neurontin
Lyrica
□
□
□
Flexeril
Zanaflex
Voltaren
Elavil
Baclofen
Others _______________________________________________________________________