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For Patients

Pain Center Admission Forms

For your convenience and in order to expedite the admission process, we ask that you download the forms listed below, fill them out completely, and bring with you on your first appointment date.

Interventional Pain Management

If your assigned physician includes:

Dr. Thomas Apostle, Dr. Laura Audell, Dr. Jana Baumgarten, Dr. Azita Far, Dr. Viliam Furdik, Dr. Leticia Lau, Dr. Yong-Jian Lin, Dr. Ken Paresa, Dr. Gary Rosengarten, Dr. Howard Rosner, Dr. David Scott, or Dr. Christropher Zarembinski

Please complete and bring the following forms with you.

• Conditions of Admissions
• Notice of Privacy Practices
• Pain Evaluation Form

Program for Headache, Orofacial Pain & Sleep Apnea

If your assigned physician is either Dr. Steven Graff-Radford or Dr. Alan Newman, please complete and bring the following forms with you.

• Conditions of Admission
• Notice of Privacy Practices
• Head and Neck Pain Evaluation Form

The forms below should be substituted for the Head and Neck Evaluation Form if you are being seen for either of the following conditions:

• If you are experiencing sleeping problems, please complete the Sleep Evaluation Form
• If you are experiencing numbness, please complete the Numbness Evaluation Form.

Instructions

If you are scheduled for a procedure, you may download instructions preparing you for sedation by clicking on the icon below. This material should be read a minimum of six days prior to your procedure. You may also call (310) 423-9857 for an automated message outlining the same information. Procedures, Medicines and Instructions.

The Pain Center Team

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