Call Us Today: 952-841-2345

Call Us Today: 952-841-2345

Imagine your life
with less pain

Schedule an
appointment with the
experts at Twin Cities
Pain Clinic and let us
help you get back the
life you deserve.

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.

Illustrated Icon of New Patient Intake Form-Twin Cities Pain Clinic Forms

New Patient
Intake Form

Illustrated Icon of Checklist-Twin Cities Pain Clinic Established Patient Intake Form

Established Patient Intake Form

Medical Records
Release

Illustrated branded icon-Two hands shaking-Appointment of Representative Authorization

Appointment of Representative (AOR)

Controlled Medication Agreement (CMA)

Controlled Medication Agreement – Pain Pump

Controlled Medication Agreement – Suboxone

Illustrated brand icon_Simple document with cannabis leaf next to it-Minnesota Medical Cannabis Form

Medical Cannabis
Patient Form

Low Back Disability Questionnaire

Illustrated brand icon_Neck Disability Index_Simple document with a human outline and pain lines coming from neck-Twin Cities Pain Clinic Neck Disability Index

Neck Disability
Index

Illustrated brand icon-outline of human with implanted device standing next to IMPLANT document-Spinal Cord Stimulation

SCS Informed
Consent-IMPLANT

Illustrated brand icon-outline of human with implanted device standing next to TRIAL document-Spinal Cord Stimulation

SCS Informed
Consent-TRIAL

Depression Screen
PHQ-9

Illustrated Icon of Checklist-Twin Cities Pain Clinic Established Patient Intake Form

PACT
Consent Form

Illustrated brand icon-Clipboard with human outline and checkboxes-Twin Cities Pain Clinic Health Assessment

Health Assessment Questionnaire (HAQ-DI)

Illustrated brand icon-simple document with Intracept title-Twin Cities Pain Clinic Intracept authorization form

Intracept Authorization Form

Illustrated brand icon_Simple document with padlock next to it

Privacy Policy

Illustrated branded icon-Simple document with dollar sign next to it-Twin Cities Pain Clinic Financial Policy

Financial Policy

Illustrated icon-hand beneath medical cross

New Patient Medical
Records Release

Pain Pump Informed
Consent – Implant

Pain Pump Informed
Consent – Macro Trial

Illustrated brand icon-Simple document with title of Micro Trial next to a pain pump-Twin Cities Pain Clinic pain pump trial

Pain Pump Informed
Consent – Micro Trial

Medical Records Release
Burnsville Surgery Center

Medical Records Release
Twin Cities Surgery Center

COVID-19 UPDATE >>
Telemedicine and in-clinic appointments available. Schedule today: 952-841-2345