Fill out and use these two forms if you are a NEW Spine or Pain Management Patient with Interventional Spine and Pain Rehabilitation Center.
You should print and sign the forms, but may be able to email directly to us. You will also need a photo ID and your insurance card, or Medicare/Medicaid Card at the time of your initial appointment. Laws and Regulations governing us as a doctor's office make us copy your insurance card at every visit. We are sorry than some patients are offended by this and the fact that we are required to randomly drug urine screening on every patient. We hope that one day we are permitted to implement reasonable judgement on who we do and do not screen, but until that day we must comply with these regulations governing us as a state certified pain management center. On the bright side, you will have NO ADDITIONAL COST to your visit from the lab that processes your urine. Your urine is also checked for blood, protein, glucose and all the common things looking for in a patient with pain, especially back pain.
If you consider yourself to be a "Chronic Pain Patient" and you have been suffering with pain for greater than three months, please also fill out the additional "chronic pain form"
Understanding opioid dependence
Opioid dependence—physical addiction to prescription painkillers and heroin—affects many people in the US. Unfortunately, many people who struggle with opioid dependence may be reluctant to ask for help because of the stigma attached to the notion of "drug dependence."
Opioid dependence is a complex health condition with many elements that are caused or made worse by continued opioid use. Key elements include social, psychological, and biological components. Opioid dependence can occur as the brain adapts to the regular use of opioids over time. People who are opioid dependent may continue using opioids despite experiencing harmful consequences.
You are not alone
Opioid dependence is a chronic disease that can affect anyone. It could be a friend, a co-worker, a spouse, a brother, a sister, or a parent.
If you or someone you know may be dependent on opioids, you are not alone. In 2013, there were nearly 2.4 million reports of people† that had abused or were dependent on opioids—such as heroin—or prescription painkillers.‡
Know your opioids: Opioids can be prescription painkillers. For example, Oxycodone, hydrocodone, and fentanyl—better known by the brand names as OxyContin®, Vicodin®, Percocet®, and Actiq®—are opioids. The street drug heroin is also an opioid.
†12 years or older.
‡Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings.NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
All brand names cited above are the property of their respective owners. Vicodin is a registered trademark of Abbott Laboratories. Percodan and Percocet are registered trademarks of Endo Pharmaceuticals, Inc. Actiq is a registered trademark of Cephalon, Inc. MS Contin and OxyContin are registered trademarks of Purdue Frederick Compa
The initial Guide to the Suboxone Program is a general overview for patients seeking help surrounding Suboxone and Opiate Addiction. It is not all inclusive and it is provided as a service to patients, clients and famlies dealing with the bahaviors of addiciton. It is recommended prior to entering the program if a patient is medically stable enough to review.
You will need to fill out both forms and either Fax, eFax to Email or take a high quality picture of both forms and a Photo ID such as driver's Lic. and send directly to the Doctor's cellphone. (yes this has worked) once all three are reviewed you will have "remote exam and assessment" by Skype, Phone, Facetime or other method. All HIPPA regulations do apply. Again, these forms and this care is for when the Doctor is not on the island at the time of need. You can follow-up with Dr Mike when he gets on island or your regular doctor, or any Doctor/healthcare advanced practitioner of your choice. There is no additional cost for the follow-up face-to-face visit with Dr Mike.
100$ US, 75$ is seasonal on-island worker or with Military ID
Interventional Spine &Pain
We occasionally have phone issues. alternate
phones 614 975 1003 and 614 493 6631
These are Handouts provided in the office at the time of informed consent or for patients considering treatment. They are provided as informational materials for patientsand loved-ones undergoing treatment and having additional quesitons about procedures
Use these TWO forms if you are a NEW Suboxone® or Buphrenorphine Patient.
You should print and sign the forms, but may be able to email them to us