1002 N Spokane Street
Post Falls, ID 83854

208.457.7078

 
 
 
     
 

Patient Forms

When making an appointment with Inland Northwest Anesthesia and Pain in Post Falls, you can ask what forms need to be filled out for your visit. The below new patient information and pain management forms will help you save time at your appointment. Just print out the form you will need to bring and fill it out at your convenience before your appointment.

 

 
   
     
 

NEW PATIENT FORM

This form is demographics form. We need to make sure you initial the HIPPA and Medication Refill lines. We have the HIPPA policy available at the office for your review.

 

 

 

 

 
 

PAIN CONSULTATION FORM

This form is a medical history questionnaire, please feel free to bring in a list with your medication and/or surgeries and we will copy it for you so you don’t have to write it all on the form.

 

 

 

 

 
 

PAIN TREATMENT AGREEMENT

There are two pages to this form. The first page is for you to read and sign that you understand it. The second page is to describe where you pain is and the level it is at.

 

 

 

 

 
 

PRACTICE MODEL

This form describes how we can manage your pain consultation between diffrent providers in our practice. Please review this form and sign it.

 

 

 

 

 

1002 N Spokane Street
Post Falls, ID 83854
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208.457.7078

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