Revive Pain & Spine Center

Sacramento Personal Injury Medicine

Schedule Online

Or Call

1-530-650-8333

Revive Pain & Spine Center

Personal Injury Referral Form

At Revive Pain & Spine Center, we understand that personal injuries can be stressful and overwhelming. Our dedicated team in Sacramento is committed to providing compassionate care and effective treatment for patients referred to us for injury recovery.

For your convenience, you may either fill out the online form below or download the Personal Injury Referral Form as a PDF. The PDF form can be completed electronically or by hand and faxed to our office. This ensures a seamless referral process and timely care for your patient.

Download PDF Form for Fax

Referring Provider Information:

Provider’s First Name

Provider’s Last Name

Provider’s Practice/Organization

Provider’s Phone Number

Provider’s Email Address

Referral Date

Patient Information:

Patient’s First Name

Patients Last Name

Patient’s Date of Birth

Patient’s Phone Number

Patient’s Email Address

Patient’s Insurance Provider

Reason for Referral

Clinic Address

3609 Mission Ave Suite D
Carmichael, CA. 95608

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Opening Hours

Mon-Thurs 9am-5pm
Friday / Saturday / Sunday
by Appointment Only

Phone

1-530-650-8333

Fax

1-530-650-8388

Additional Information / Instructions

Medical Documents Upload:

Select Files

To send via fax, please fax all valid documentation to the following number: 1-530-650-8388.

Additional Notes

* I acknowledge that the information provided is accurate and consent to the referral process.

* I consent to sending confidential patient documents via this referral process.

* Basic Fields marked with a (*) are required. Review Our Privacy Policy Here.

Take Your First
Step Toward Healing

Heal naturally and regain your active lifestyle.

If you’re tired of living with pain and want to explore non-surgical options to accelerate your recovery, regenerative medicine may be the solution you’ve been looking for. Dr. Akbar Khan and the team at Revive Pain & Spine Center in Sacramento, California are ready to guide you on your journey to pain relief and healing.

Take Your First Step

1-530-650-8333