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Get Online Pain Management Consultation Form

Ppointment) Requesting Doctor Name: Patient Name: Clinic Address : Acct No / IC No: Address: Stick Patient Label here Contact No: (Off) (Fax) Contact No: (Off) Date: Signature: Ward: (HP) Bed: Clinical History Drug Allergy : ( To be completed by requesting doctor ) Purpose of Referral : ( Please indicate: Pain location / Duration / Neuropathic / Cancer / Mechanism of Pain ) Clinical Issues : Please circle accordingly: Non-Subsidised / Subsidised ( DM / Hypertension / IHD / Rena.

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