Restore Pain Center
Referral Coordinator
Starting with a new pain management provider can feel overwhelming — but it doesn't have to be. We'll help you through every step of the process.
Before Your Appointment, We'll Need:
Don't worry — we'll help you obtain each of these. Use the forms and instructions below.
The Process
How It Works
Contact Our Office
Call or submit an online inquiry to let us know you'd like to become a patient. You may schedule your appointment before your referral is received.
Download Your Forms
Use the forms below to authorize your records release and request your medication profile. Print, sign, and give them to your providers.
Ask Your Provider to Fax
Give the referral request form to your primary care provider. Ask them to fax your referral and supporting records to our office.
We'll Confirm Your Appointment
Once your referral is received, our team will confirm your appointment and send you portal access to complete intake forms in advance.
Physician Referral Required
You may schedule an appointment before your referral is received. However, we must receive a referral from your primary care provider before you can be seen.
Please ask your primary care provider's office to fax the referral to:
Referral Fax: (601) 510-5268
Patient Forms
Download Your Forms
Print, sign, and give each form to the appropriate provider. All forms are fillable PDFs — you can type directly in them before printing.
Provider Referral Form & Fax Cover Sheet
Give this to your primary care provider's office. It includes a pre-filled fax cover sheet and a referral request form they can complete and fax directly to us.
For your PCP's officeDownload FormCombined HIPAA Authorization Forms
Authorizes your healthcare providers to release your medical records and relevant health information to Restore Pain Center / PPOG for the purpose of pain management care.
For your current providersDownload FormPharmacy Medication Profile Request
Take this to your pharmacy and ask them to fax your current medication profile directly to our office. Includes checkboxes for active prescriptions, controlled substances, and fill history.
For your pharmacyDownload FormFor Referring Providers
What Your Provider Should Send
Please ask your primary care provider to fax the following to Restore Pain Center:
- Referral to Pain Management
- Most recent office visit notes
- Current medication list
- Relevant imaging reports (MRI, CT, X-ray)
- Relevant laboratory results (if applicable)
- Other records related to your pain condition
Referral Fax
(601) 510-5268
Professional referrals only — please include patient name and DOB on cover sheet
Day of Appointment
What to Bring
Please bring the following to your first appointment:
- Valid government-issued photo ID
- Payment for today's visit
- Any imaging discs or reports you have available
- Any additional medical records not previously submitted
Payment Policy
Restore Pain Center is a cash-pay practice. Payment is due at the time of service. Patients may request a superbill for possible out-of-network reimbursement.
We're Here to Help
Questions About the Referral Process?
If you have questions about referrals, medical records, required documentation, or preparing for your appointment, our team is happy to help.