Office Forms

  • Referring Patients to Sussex Pain Relief Center
  • Before patients are given an appointment, the following must be sent to The Sussex Pain Relief Center by fax (302-253-8028):

  1. Physician Referral Form
  2. The most recent history and physical
  3. Last three office notes pertaining to the patient’s pain problem
  4. Any pertinent diagnostic tests such as MRI, CT scans, EMG or NCS
  5. Patient insurance and demographic information
  6. Copy of the last prescription

Patient Forms

  • Pain Questionnaire
  • The above multi-page questionnaire is a vital tool that is used to assess your pain condition as well as the appriopriate treatments for you problem. Please read and fill out every single item in this form, including the demographic information on the first two pages. Please also include your signature where requested. Failure to complete or sign this form could result in a delay in your appointment. Please bring the completed form along with any pertinent films, reports, doctor notes, complete medication list, and prescription bottles for your initial consultation.

  • Notice of Privacy Practices

Record Requests