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Referring Patients

To refer your patient for an appointment with one of our physicians, please complete our referral form or send a fax with this information to 515-280-6954. Once we receive your request, we will contact your patient directly and schedule an appointment within 24 hours.

If you have any questions, please contact our office at 515-245-6425.

Patient Referral Form

Please complete the following form and one of our appointment schedulers will contact your patient by phone to schedule an appointment.

All data collected in this form will be reviewed and confirmed by the referring physician before an appointment is scheduled.

Referring Office Contact Information

Referring Provider:

Office Contact:

Office Phone:

Email Address:

Fax Number (Optional):

If you would like a confirmation of your patient's appointment, please provide your fax number.

Patient Information

Patient Name:

Date of Birth:

Patient Phone Number:

Patient Email Address (Optional):

Patient Insurance (Optional):

Symptoms & Diagnosis:

Injection TherapyMedication Management

Was this injury/condition related to Workers' Compensation?


Patient Has Completed:


Requested time to be seen:

1-2 days3-5 daysNo preference

We will be in contact with you to acquire information about patient demographics, insurance information, prior authorizations, diagnostic reports, physician notes and a current list of medications.

If your patient needs to be seen immediately, please call our office at 515-245-6425.


Pain Specialists of Iowa

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