Call Us Today: 952-841-2345

Call Us Today: 952-841-2345

Patient Forms

Thanks for choosing Twin Cities Pain Clinic. In order to provide you with the best possible care, we would like to know a bit about you. Please select the appropriate form from the list below and complete it prior to your next appointment. You may fill out the form online, or print it and bring it to your visit.

Please select the appropriate form from the list below and complete it prior to your next appointment. You may choose to fill out the form online, or you can print it and bring it with you to your visit.

  • All
  • Current Patients
  • New Patients
  • Consent Forms
  • Questionnaires
New Patient
Intake Form
Established Patient Intake Form
Medical Records
Release
New Patient Medical
Records Release
Appointment of Representative (AOR)
Controlled Medication Agreement (CMA)
Controlled Medication Agreement – Pain Pump
Controlled Medication Agreement – Suboxone
Medical Cannabis
Patient Form
Health Assessment Questionnaire (HAQ-DI)
Low Back Disability Questionnaire
Neck Disability
Index
Intracept Authorization Form
Depression Screen
PHQ-9
Financial Policy
Privacy Policy
COVID-19 UPDATE >>
Telemedicine and in-clinic appointments available. Schedule today: 952-841-2345