Refer A PATIENT

THE REVIVE TEAM is here to help you and your patients. When you 

refer your patients to Revive Spine and Pain, our best-in-class interventional pain management specialist will work with you to identify the cause of their pain and give them real relief. Same-day appointments are available. Please complete the form below and fax it and the following items to our secure office fax at (833) 471-4559.

• Physician Referral Form
• Insurance Card
• Patient Demographics
• Any applicable medical records, including MRI copies