For your convenience, The Pain Treatment Center of the Bluegrass offers these online forms for you to fill out prior to your appointment at our facilities. Please complete every section so we have the information we need to provide you with prompt treatment and medical care. The instructions should be self-explanatory, but if you have any questions, please don’t hesitate to call us for assistance.
All PDF documents on this page are in a fillable format. You will need software capable of opening such files (such as Adobe Acrobat Reader).
You may complete and submit these forms to The Pain Treatment Center of the Bluegrass in any of the following ways:
Type your answers directly into the document and save it to your computer. Then, you may either:
- Email it as an attachment to the appropriate department; or
- Print out the completed form and mail or fax it to the appropriate address/fax number.
Medical Records Release: firstname.lastname@example.org
Patient Portal Enrollment: email@example.com
Patient History Form: firstname.lastname@example.org
Referral Form: email@example.com
Employment Application: firstname.lastname@example.org
After printing the form and filling it out by hand (using black or blue ink), mail or fax it to the appropriate address/fax number.