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Patient Information
Patient's Name*
Phone*
Email
Address
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Month
Day
Year
Insurance*
Provider Information
Provider's Name*
Provider's Office Name*
Phone*
Fax
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Condition to be treated*
Notes
How APT can help you
- 24/7 post-operative pain concierge service – a doctor always available by phone to help even at night
- Optimizing pain medications
- Nerve block/catheter
- Nerve cryotherapy
- Radiofrequency ablation
- Ketamine infusions
- PRP Injections
- Buprenorphine
- Joint injections
- Epidural steroid injections
- Peripheral nerve stimulation
- Spinal cord stimulation
- Botox for headaches
- Nerve blocks for headaches
- Nerve catheter for rib fractures
- Nerve catheter post-herpetic neuralgia
- Nerve catheter for post-traumatic pain
- Ketamine for depression
- Ketamine for acute pain
- Ketamine for chronic pain
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