Physician Referrals Referring A New Patient

Southern Michigan Pain Consultants appreciates the referral of your patient with pain. We want you to know that we intend to work with you and your patient together in finding relief for their pain.  We will do everything possible to make sure the lines of communication are open and clear regarding the treatment and progress of your patient. If you would like to refer a patient to Southern Michigan Pain Consultants you have a few options.

  1. You can submit a patient referral online by filling out the form below. Just give us a few pieces of information and we will call the patient to set up the appointment for you and call you back to let you know the date the appointment is scheduled, for your records.*
  2. You can call (800) 319-3118 and a scheduler will set your patient up at the clinic closest to their home or work unless otherwise requested by the referring office.
  3. If you prefer to utilize our Fax Referral, you may contact Dan Haskins. We will personally drop the forms off for you and answer any questions you may have about the process. Please note: the fax form is the same format as our online referral form except it is faxed. If you like you may also fill out the form below, print, and fax it over to us.*
  4. Southern Michigan Pain Consultants participates with Great Lakes Health Connect. Great Lakes Health Connect is Michigan’s largest health information storage and exchange and provides a safe, secure platform for seamless patient referrals. All Southern Michigan Pain Consultants locations and providers are live on Great Lakes Health Connect. For more information on how to utilize Great Lakes Health Connect, please visit their website at
*These processes are designed to save you and your busy office staff time on the phone. With both online referral and fax referral we can get you off the phone in just a few short minutes.

Online Patient Referral Form

Fast Track Scheduling

SMPC Scheduling: 877-377-6227  Email:

Additional med recs can be emailed to address above or faxed to 800-940-9601.

To print a copy for your records, fill out then hit File > Print, from the File Menu before you select ‘Submit this Form’.

Please complete this form and click ‘submit by email’ above. Our scheduling department will call the patient to set up appointment and then call you to let you know appointment has been set. Red asterisk indicates required information. Thank you for the referral.