What to expect during your first visit:

We ask all patients to fill out these forms.

Some of these forms are old and will be updated soon.

We are requesting a referral from your physician (primary care or specialist) to be able to see you. The referral information together with any pertinent information (last office visit, MRI/CT reports if applicable) can be faxed to our office at 682-518-1334.

We will perform urine drug screens on every new patient and also randomly.

We do not prescribe soma (carisoprodol) or benzodiazepines like xanax or ativan.

Some forms are mandated by Federal and State Laws (HIPAA) some are required by us to ensure financial responsibility.
All forms are posted on this website so patients can fill them out at home before their first visit.

Click here for our Welcome Letter. To download it in rtf format, in pdf format, and in Microsoft doc format.
To download Adobe Acrobat Reader click here .

Click here for our New Patient Form. To download it in rtf format, in pdf format, and in Microsoft doc format.

Click here for our New Workers Compensation Patient Form. To download it in rtf format, in pdf format, in Microsoft doc format. This form has to be filled out by Workers Compensation patients only.

Click here to download our Patient Health Questionnaire in rtf format, pdf format or Microsoft doc format.

Click here for the Consent and Information Release Form. To download it in rtf format, in pdf format, and in Microsoft doc format.

Click here for the Release of Information to PSTX Form. To download it in rtf format, in pdf format, and in Microsoft doc format.

Click here for the Protected Health Information (PHI) disclosure Form. To download it in rtf format, in pdf format, and in Microsoft doc format.

Click here for our Payment Policy Form. To download it in rtf format, in pdf format, and in Microsoft doc format.

Click here for the Long-term Controlled Substances (LTCS) Agreement. To download it in rtf format, in pdf format, and in Microsoft doc format.

We also ask you to fill out this Brief Pain inventory Form (comes only in pfd format) to provide us with some standardized information about your pain problem.

Brief Pain Inventory (BPI) Form.
 

For some other miscellaneous forms click here.

If you have any questions regarding these forms, please do not hesitate to contact us.

All patients will have a thorough History and Physical performed.
 

Patients will be asked to read and sign a Long-term Controlled Substances Agreement and to provide us a urine sample for testing purposes.

Patient who refuse to sign the agreement or are unwilling to give a urine sample will not be prescribed any controlled substances including opiates (like hydrocodone, oxycodone, morphine, fentanyl, methadone) and benzodiazepines (Valium - type medication). These patients will only receive non-controlled medication and could be potential candidates for interventional procedures.

These patients will also be offered referral for substance abuse counseling.

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Copyright © 2009 Pain Specialists of Texas. Last modified: 03/20/11