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!

2101 S. Arlington Heights Rd., Suite 165

Arlington Heights, IL  60005

tel:  (847) 593 - 6800

fax:  (847) 593 - 6803

724 Florsheim Drive

Libertyville, IL  60005

tel:  (847) 593 - 6800

fax:  (847) 593 - 6803

240 Center Drive

Vernon Hills, IL  60061

tel:  (847) 367 - 8100

fax:  (847) 367 - 8335

 If you're in pain or simply have more questions, please call us today so that we can help to set you on a path to a more enjoyable life!

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