Appointment Request Form

Thank you for considering Pain Specialists of Lancaster for your pain management needs. Please complete and our office will contact you to schedule an appointment.

Referring Physician: Referring Physician Phone:
Family Physician: Family Physician Phone:

Your Name: Birthdate:
Address: Phone Number:
Address: Please provide a phone number where you can be reached between 8am 3 pm.
E-Mail Address:

Physician Requested: Dr. Simons   Dr. West

What caused your pain?
Please provide a brief description of your pain:
Have you had any x-rays, CT scans or MRIs that were taken because of your pain? Yes   No
If so, when and where were these tests done?
Have you done physical therapy? Yes   No
If so, when and where did you have the physical therapy?
Are you currently taking any medicine for your pain? Yes   No
If so, please list:

Your insurance company: