For Health Care Providers


Referral form

If you are a doctor, a health care provider or a doctor's representative, you can download and fax the "referral form" below to 281-998-3331. We will immediately make all the necessary arrangements directly with your patient and keep you informed. If this method is inconvenient, please fell free to use our online submission form found in the "contact us" page; please indicate that you are a doctor's office on the box provided for comments. Thank you.

Referral Form (for Health Care Providers ONLY)

CLINICS POLICY ON REFERRALS. We prefer our patients to be under the oversight of a Primary Care Physician whenever possible. If the patient does not have a PCP, we generally assist him/her in obtaining one. One of our MAIN goals is to assist the primary care physician in providing a consultative (evaluation/management) service consisting of an assessment of the causes (i.e, identification of pain generators) and mechanisms of the patient's pain and then provide the treatment (interventional or non-interventional). Thereafter, patients are generally referred back to their primary care physician with detailed guidelines for long term management, UNLESS we are requested to manage the patient's pain on long term basis. Our general preference is to provide evaluation, initial treatment and a consultative report to the primary care physician for long term management.

We also accept referrals with specific instructions to perform a particular procedure from specialists and primary care physicians (i.e., spinal cord stimulator trial, vertebroplasty, selective nerve root block, etc.) Please request this specifically in the referral form.

St Michael's Neurology and Pain Medicine
2646 South Loop West, Suite 106
Texas Medical Center

Houston, TX 77054
Phone: 713-364-0087
Fax: 281-822-0480
Office Hours

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