Referral Process

Internal Physician Referral Process
 U-M physicians please send Standard Consult Form.
Download the Internal Physician Referral Request Form PDF here.

External Physician Referral Process
External physicians (outside UM) please download the PDF, and fax the completed form to 734.936.6585.
You may also request the form by calling the Back & Pain Center at 734.763.5459.

All Physicians
The following information will help us to gain a more thorough understanding of your patient's pain issues:

  • Patient demographics
  • Diagnosis, reason for referral and current pain medications
  • Reports (office notes regarding pain problem, CT, Xray, MRI, EMG etc)
  • Referring physician phone number and UPIN number


Please feel free to call us at 734.763.5459 if you have any questions or concerns.