Pain Center Admission Forms
For your convenience and in order to expedite the admission process, we ask that you download the forms listed below, fill them out completely, and bring with you on your first appointment date.
Interventional Pain Management
If your assigned physician includes:
Dr. Laura Audell, Dr. Azita Far, Dr. Viliam Furdik, Dr. Leticia Lau, Dr. Yong-Jian Lin, Dr. Gary Rosengarten, Dr. Howard Rosner, Dr. David Scott, Dr. Christopher Zarembinski, Dr. James Nguyen, Dr. Bahman Shamloo or Dr. Mary Alice Vijjeswarapu.
Please complete and bring the following forms with you.
- Pain Evaluation Form (PDF)
Headache, Orofacial Pain and Sleep Apnea Program
If your assigned physician is either Dr. Alan Newman or Dr. Katayoun Omrani, please complete and bring the following forms with you.
The forms below should be substituted for the Head and Neck Evaluation Form if you are being seen for either of the following conditions:
- If you are experiencing sleeping problems, please complete the Sleep Apnea Evaluation Form (PDF).
If you are scheduled for a procedure, you may download instructions preparing you for sedation by reading: Procedures, Medicines and Instructions (PDF). This material should be read a minimum of six days prior to your procedure. You may also call 310-423-9600 to speak to a nurse regarding your procedure.