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HELMCKEN PAIN CLINIC – INTERVENTIONAL PAIN MANAGEMENT 211 – 284 Helmcken Rd, Victoria BC, Canada V9B 1T2 Appts: 250-595-5905 Fax: 250-595-5907 www.helmckenpainclinic.com (Please mail if sending more than 5 pages) Date Patient Information Referring Physician Name DOB MSP (WCB#) Address/PC Phone# Alt Phone # Name MSP# Address Phone# Fax# Family Physician Fax# Patient to See ☐ Dr. D. Vincent MD FRCPC ABDA ☐ Dr. B. MacNicol MD FRCPC CHSE Duration of Symptoms Body Part ______________________ ☐ FIRST AVAILABLE ☐ <1 mo ☐ 1-6 mo ☐ 6-12 mo ☐ 12-24 mo ☐ 24+ mo ☐ Low back ☐ Upper Back ☐ Neck ☐ Shoulder ☐ Head ☐ Arm ☐ Leg ☐ Other ________________________________________________________ Reason for Referral (include relevant symptoms, physical findings and treatment to date) (☐ Letter attached) (☐ This is or may be CRPS – complex regional pain syndrome, ☐ post-herpetic neuralgia , or ☐ other neuralgia) Past Medical & Surgical History (☐ Letter attached) Medications (☐ Letter attached) Allergies (☐ Letter attached) Has the patient had injections in the past? (List attached ☐) Has the patient been through a comprehensive chronic pain program such as the RJH or NRGH? ☐ Yes ☐ No Have appropriate X-Rays / Diagnostic tests been obtained / ordered? ☐ ☐ Yes – results attached No – Please indicate exceptional circumstances in the space below Upon review, receipt of referral will be confirmed via fax to referring physician’s office. An approximate wait for the appointment will be indicated. Patients will be contacted directly to schedule appointments. Please ensure that your patient completes the brief pain inventory (attached) and brings it with him/her to his/her first appointment.