Inland Pain Specialists

​​If you are a NEW PATIENT, please download and provide this referral form to your doctor in order to be seen at our offices.

​​Dear Patients, please understand, at your appointment you will need to bring the following 3 items -

1) Valid government issued  picture ID card;

2) Insurance Card

3) Referral Letter from your physician (for new patient)

NOTICE: Inland Pain Specialists  does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.

New Patient Referral Form

Center for Pain Management & Addiction Medicine