Request an
Appointment
Please do not use this form if you have an urgent medical problem or you need to reschedule an existing appointment. Instead, contact our office at (954) 580-8838. After you submit your request, our appointment scheduler will respond within 48 hours. See below for forms to complete.
Patient Registration Forms
Anesco Interventional Pain Institute welcomes you to our practice. Once you have made your initial appointment, you may download and print the form(s), fill them out, and bring them with you to your first visit. Completing the forms prior to your visit will help speed up the new patient registration process.
If you have not downloaded and completed patient forms ahead of time, please arrive 30 minutes prior to your first scheduled appointment in order to complete the required paperwork.
Be sure to bring the following items with you to your first appointment:
- Driver’s license or other identification
- Insurance card(s)
- If you have an HMO insurance plan, you must have your referral with you
- Your advance directive, if available
- A list of medications that you are currently taking, including over-the-counter drugs, vitamins, and herbal supplements
- Your pharmacy telephone number
- Any relevant medical records
- Diagnostic films (MRI, CT, X-rays, etc.) or other test results that may have been ordered or performed by another physician, and any applicable written reports or multi-media materials (CD)
Downloadable Forms:
- Initial Consultation and Patient Information Form
- Pain Medication Agreement
- AIPI Consent Form
- HIPAA Notice of Privacy
- Telemedicine Informed Consent
Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.
