Referral Forms  (for healthcare providers)

​If you would like to refer a patient to our practice...

1.  Please print and fill out the referral form below  

2.  Fax it to our office at (847) 593-6803

3.  We will contact the patient and schedule their initial consultation.

(If available, please fax recent physician notes as well as reports of any diagnostic reports including: MRI, CT, X-rays, EMG, U/S, labs, etc.)



Referral Form (for healthcare providers)


Get pain relief now – call today to learn how Innovative Pain Specialists can help!