Comprehensive Pain Management
(Formally known as Franklin Pain and Wellness and Warwick Pain)

Attleboro, MA(508) 236-8333
Franklin, MA(508) 541-0004
South Kingstown, RI (401) 234-9677
Warwick, RI(401) 352-0007

Franklin, MA • (508) 541-0004
Warwick, RI • (401) 352-0007
South Kingstown, RI • (401) 234-9677

Comprehensive Pain Management Patient Referral Form

Doctors Information:


Email Address:*

Please upload the following files:

  • MRI's (pertaining to pain)
  • Medication List (inc. current dosage and instructions)
  • Last MD note

Attach Files Below (100Mb Limit), Click 'Browse' to upload your files:

Patient Information:

Patient Name *

Patient DOB *

Home Phone:*

Cell Phone:





Reason for Referral *

Is Patient on any Anticoagulation Therapy? Yes No

Insurance Information

Primary Insurance:

Policy Number:

Insurance Referral or Authorization Number:

Start & End Dates:

Number of Visits:

Office Location:*
Franklin MA Warwick RI South Kingstown RI