Total Pain Care

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PRE-REGISTRATION

Pre-Register with Total Pain Care

Welcome to Total Pain Care's online pre-registration. By gathering the following information you can speed up the process of becoming a Total Pain Care patient.

Please Fill Out the Required Information

Name:

E-mail Address:

Requested Doctor:

First Available
Dr. Eric Pearson
Dr. Ken Staggs

How did you hear about us?:

Television
Word of Mouth
Referred by Physician
Web

Date:

Date of Birth:

Address:

City:

State:

ZIP Code:

Cell Phone:

Home Phone:

Work Phone:

Other Phone:

Referring Doctor's Office:

Referrer's Phone:

Referrer's Fax:

Insurance Information:

Please select you insurance provider from the list at the right

Medicare
Medicaid
Tri-Care
Blue Cross Blue Shield

Other Commercial

Workers' Compensation

Pain Complaint:

Please list any special request or additional information that would be helpful in making sure the referring physician's concerns are addressed

Family Doctor:

Previous Physicians:

Previous Studies:

MRI
X-Ray
CT Scan

Bone Scan
EMG or Nerve Study
Labs