Edgewood, Kentucky : Phone: (859) 331-4159
PATIENT FORMS
The Advanced Pain Treatment Center is committed to providing the highest quality, state-of-the-art and safe medical care to the pain patient. The center strives to reduce or eliminate pain when possible, and improve function and quality of life. For your convenience, the following forms are provided for your convenience in advance of your appointment with Dr. Gupta.


Patient Information & New Patient Forms

Please download the following the forms if you choose to complete patient forms at home prior of your initial appointment. Bring the completed forms to your appointment at the Center.

→ Notice of Privacy Practices

→ Background Questionnaire

→ Forms: Patient Consent

→ Forms: Patient Registration

→ Forms: Postprocedure Pain Diary

→ Forms: Preprocedure Check List

→ Forms: Release of Patient Medical Records

→ Post Facet Joint Diagnostic Block Form

→ Patient Information: Cervical Transforaminal

→ Patient Information: Lumbar Transforaminal Injection

→ Patient Information: Sacroiliac Injection

→ RF Ramii Communicantes

→ Patient's Bill of Rights

Appointments by Phone
Calls may be monitored or recorded for quality purposes.

Edgewood, Kentucky
162 Barnwood Drive
Edgewood, KY 41017
(859) 331-4159 • Fax (859) 331-4163

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