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Valley Pain Consultants
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Patient Portal
540-450-2339
About Us
Conditions & Treatments
Interventional Pain Care
Head/Neck Pain
Mid/Low Back Pain and Sciatica
Abdominal and Pelvic Pain
Arthritic Pain
Hip/Knee/Ankle Pain
Shoulder/Elbow/Hand Pain
Bursitis/Tendonitis
Fibromyalgia/Nerve Pain and CRPS
Headache and Facial Pain
Patient Information
Our Providers
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For Referring Providers
540-450-2339
VPC ONLINE PATIENT REFERRAL APPLICATION
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Full Provider's Name (Dr. First, MI, Last, Title)*
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Name of Practice for the Provider*
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Provider's valid email address*
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Patient's Full Name (First, Middle, Last)*
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Patient's Primary Phone Number *
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Date of Birth *
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Patient's Insurance Information (Primary, Secondary, etc.)*
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Does the Patient's insurance require pre-authorization? (Yes/No)*
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Diagnostic Studies/Reports**
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Reason for Referral*
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