Downloadable Forms

Referring physicians can download our referral form here. Patients can download our clinic visit questionnaire to pre-fill before their next medical visit, and can re-read our chronic pain management agreement to understand our mutual expectations for success and safety.

Doleys Clinic - Pain Clinic Birmingham
Fax Referral Form for All Services

For health care providers who wish to refer patients to our clinic -- please download the form, check the appropriate box and fill in patient info.  Fax in with recent medical notes. We thank you for your referral!

Doleys Clinic - Pain Clinic Birmingham
Pain Clinic - Medical Visit Follow-Up Questionnaire

For follow-up visits only -- print & complete this form to save time before your next medical visit.

Pain Clinic - Agreement

When you're given the agreement at the clinic, please read thoroughly and know what you're signing!

 

Please watch this brief video to the right as Dr. Doleys explains the highlights of our clinic's agreement.