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Interventional Pain Medicine patient referral form

The COVID-19 health crisis has affected clinic operations throughout UK HealthCare. Please see our information for referring providers.

We appreciate the opportunity to be of service to you and your patient.
Please complete this form and click 'submit' to refer to us electronically, or print the form and fax it to 859-257-6768.

Patient Information
Patient Name
Mailing Address
Insurance Information
Copies of insurance cards are acceptable in lieu of completing this section. If Worker's Comp or Motor Vehicle coverage is applicable, please list as 'Primary Carrier.'
Referring Information