Referrals

Under Construction

Submit a no-charge referral 3333 to MSP under Dr. Jason Caplan (#35917); and Fax Referral to: 250-762-0819

Referring Physician Info:

MD Name: *

MSP #:

Tel. & Fax #:

Signature

Patient Information / or Attach Label:

Date:

Patient Phone/Cell #:

PATIENT REFERAL FOR NERVE BLOCKS/TRIGGER POINTS FOR TREATMENT OF:

HEADACHES – Migraines, post-traumatic, cervicogenic, and tension type… refractory to treatment.
NECK PAIN, SHOULDER PAIN, UPPER OR LOWER BACK PAIN (Please circle)
REGIONAL MYOFASCIAL PAIN SYNDROME
ATYPICAL FACIAL PAIN
OCCIPITAL NEURALGIA
FIBROMYALGIA

PATIENT DOES NOT HAVE THE FOLLOWING CONTRAINDICATIONS:

Actively seeking narcotics/untreated substance abuse disorder
Radiculopathy
Significant anticoagulation or Immunocompromised
Infection or unkempt condition in the area requiring treatment
Under 18, pregnant, or breastfeeding
needle phobia

Reason For Referral:

**Please ensure that the patient has been investigated for any concerning symptoms or conditions, and that these have been excluded prior to referral to the Kelowna Nerve Block and Trigger Point Clinic**

Click or drag a file to this area to upload.

Phone

Referrals

Under Construction

Referring Physician Info:

Patient Phone/Cell #:

PATIENT DOES NOT HAVE THE FOLLOWING CONTRAINDICATIONS:

Address