Instructions

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 person by clicking on the envelope to the right of the form link on this page; or
    • Print out the completed form and mail or fax it to the appropriate address/fax number
  • Or, 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.

Referring Providers

Referral Form   This email address is being protected from spambots. You need JavaScript enabled to view it.

Patients

Patient Portal Enrollment  This email address is being protected from spambots. You need JavaScript enabled to view it.
Patient History Questionnaire
   This email address is being protected from spambots. You need JavaScript enabled to view it.
Surgery Center Patient Information Guide
Notice of Privacy Practices - Surgery Center
Notice of Privacy Practices - Physician Practice

Medical Records

Medical Records Release / Request of Information - Surgery Center   This email address is being protected from spambots. You need JavaScript enabled to view it.
Medical Records Release / Request of Information - Physician Practice   This email address is being protected from spambots. You need JavaScript enabled to view it.

Human Resources

Employment Application   This email address is being protected from spambots. You need JavaScript enabled to view it.