(828) 221-0121 Access Patient Portal

HOME
ABOUT US
CONDITIONS
TREATMENTS
FOR PATIENTS
- New Patient Information Forms
- Office and Billing Policy
FOR PHYSICIANS
- Physician Contact Form
- Physician Referral Form
CONTACT US
- Asheville Location
- Columbus Location

HOME
ABOUT US
CONDITIONS
TREATMENTS
FOR PATIENTS
- New Patient Information Forms
- Office and Billing Policy
FOR PHYSICIANS
- Physician Contact Form
- Physician Referral Form
CONTACT US
- Asheville Location
- Columbus Location

Physician Referral Form

Physician Fast Track Referral Form

Patient Name *

First

Last

Patient Phone Number *

Patient DOB

Physician Name *

First

Last

Physician Practice Name *

Physician Address *

Line 1

Line 2

City

State

Zip Code

Physician Phone Number *

Physician Fax Number

Physician Email

Preferred Method of Contact *

Phone
Fax
Email
Mail

Urgency of Consult

Routine
Urgent (within 48 hours)

Reason for Consult

Type of Consult Requested

Evaluation and Management
Evaluation and Recommendations Only
Narcotic Detoxification Evaluation
Other

Phone

For Prospective Patients

Contact Us to Schedule an Appointment
Conditions We Treat

For New and Current Patients

New Patient Forms
Office and Billing Policy
Access Patient Portal

For Physicians

Refer a Patient
Contact the Physician

Contact Us

Phone: (828) 221-0121
Fax: (828) 348-4971

Asheville Clinic

1091 Hendersonville Rd. Suite 101
Asheville, NC 28803

Columbus Clinic

155 W. Mills Street Suite 204
Columbus, NC 28722

© 2018 Premier Pain Solutions | Services by Morus Medical Services

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