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Physician Refferal Form

Information from the Reffering Physician

Personal details:


Instructions on:

** The acute pain has not persisted for any longer than three months; all in all, the patient is experiencing two different types of pain at most; e.g. firstly, chronic migraine; secondly, acute lumbar back pain.

Who will cover the cost of this examination?

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On receiving this contact form, the Centre for Pain Medecine will send you a more detailed questionnarie regarding quor pain problem.

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