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.

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

Pain Pump Informed
Consent – Macro Trial

Pain Pump Informed
Consent – Implant

Illustrated icon-hand beneath medical cross

New Patient Medical
Records Release

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

Financial Policy

Illustrated brand icon_Simple document with padlock next to it-Twin Cities Pain Clinic Patient Privacy Policy

Privacy Policy

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

Intracept Authorization Form

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

Health Assessment Questionnaire (HAQ-DI)

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

PACT
Consent Form

Depression Screen
PHQ-9

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

SCS Informed
Consent-TRIAL

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

SCS Informed
Consent-IMPLANT

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

Low Back Disability Questionnaire

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

Medical Cannabis
Patient Form

Controlled Medication Agreement – Suboxone

Controlled Medication Agreement – Pain Pump

Controlled Medication Agreement (CMA)

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

Appointment of Representative (AOR)

Medical Records
Release

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

Established Patient Intake Form

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

New Patient
Intake Form

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