I wish to be contacted in the following manner (check all that apply):

By listing their names here, I authorize Maryland Pain Specialists to discuss my treatment, schedule appointments, or send records to the following persons:
PLEASE NOTE: Referring physicians are automatically eligible to receive this information so do not list them on this form.

YOU MAY RECEIVE A SEPARATE BILL FROM YOUR PHYSICIAN AND THE FACILITY

Patient Agreement and Signature

I have read and fully understand the Patient Preferred Contact Information described above. I further understand that my signature signifies that I accept the terms as set forth in this agreement.

Patient Signature