• Edgewood, Kentucky : Phone: (859) 331-4159
  • Mason, Ohio : Phone: (513) 492-9317
REQUEST AN APPOINTMENT
REQUEST AN APPOINTMENT
Complete the form below to request an appointment at Advanced Pain Treatment Center. An appointment representative will contact you within three business days to review your medical and financial information, including insurance coverage, before an appointment may be offered.
Requester Information
Who is this appointment for? *
At which Advanced Pain Treatment Center location are you requesting an appointment? *
Patient Information
Please provide patient information as it appears on legal documents.
Have you previously received care at Advanced Pain Treatment Center ? *
First Name : *
Middle Name :
Last Name : *
Address: *
City: *
State: *
Zip: *
Primary Phone: *
Secondary Phone :
Email Address : *
Gender : *
Parent name/Guardian name :
 
The name of a parent is required if the patient is under the age of 16.
Does the patient need an interpreter? :
Patient Insurance Information
Does the patient have health insurance? :
Medical Concern
What is the primary medical problem or diagnosis for the appointment request? :
How long has the patient had this problem?
Are there additional medical problems the patient needs assessed during this visit? :
Captcha : *
 
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

Mason, Ohio
6406 Thornberry Court
Unit 220
Mason, OH 45040
(513) 492-9317 • Fax: (513) 492-9325
Contact Us