Refer A Patient

Thank you for referring your patient to Twin Cities Pain Clinic for pain management treatment. It is our privilege to partner with you in their care.

Select one of the options below to securely submit your referral. Our care team will contact your patient by the next business day.

REFER ONLINE
PRINT & FAX
Fax completed referral forms to:952-841-2346

Patient Referral Form

"*" indicates required fields

Patient Information

Name*
MM slash DD slash YYYY


Referring Provider Information

Drop files here or
Max. file size: 10 MB.
    Drop files here or
    Max. file size: 10 MB.
      e.g. recent office visit notes, imaging, patient insurance information, etc.
      Drop files here or
      Max. file size: 10 MB.
        e.g. recent office visit notes, imaging, patient insurance information, etc.
        Drop files here or
        Max. file size: 10 MB.
          e.g. recent office visit notes, imaging, patient insurance information, etc.
          This field is for validation purposes and should be left unchanged.

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