The following forms are essential elements in your diagnosis and treatment by our pain specialists. The links below will allow you to download, print and fill out the requested forms at your convenience prior to your scheduled appointment.
I consent to routine medical nursing care including routine procedures, examinations, tests, immunizations, regional and local anesthesia and other treatment by Dr. Quiroga and his assistants.
Release Of Information
Notice of Privacy Practice
What is the main problem that brings you here today.
Primary Care Physician
Primary insurance provider info
Emergency contact info
Description of current pain issues
Associated problems caused by pain
Updates to medical/surgical history
Pain management goals
Acknowledgement of receipt of Michigan Advanced
Pain & Spine notice of privacy practices
Authorization of disclosure of patients' medical history
by Michigan Advanced Pain & Spine
Designed to give the doctor information as to how
your back pain has affected your ability to manage in
everyday life: personal care, walking, sleeping, social
life, travel, etc.
To identify frequency of and difficulties you may be
experiencing due to headaches
This form importantly appraises personal and family
history of alcohol or other substance abuse,
psychological disorders or sexual abuse.
This form is an assessment of any issues with balance,
dizziness, falls, hearing loss and of your need of
assistance to walk or stand.
This series of statements is designed to insure that
you understand the various risks and responsibilities
that go along with these treatments.
This self-assessment helps our clinicians monitor
patients' medication-related behaviors over the course
This form assists clinicians consider which patients
may exhibit aberrant medications behaviors in the
This form authorizes Michigan Advanced Pain & Spine
to furnish your attorney with a full report of your exam,
diagnosis, treatment, prognosis, etc. in regard to an
accident/injury in which you were involved.