Making an Online Referral to the Pain Management Service
Completing our online referral form below will assist you in generating the required Örebro questionnaire and AC6273 referral forms. A copy of these will be emailed to you upon completion of the Pain Management referral form.
Alternatively, you can still submit referrals via email, including the required Örebro questionnaire and AC6273 referral forms by PDF.
- Complete the short form Örebro questionnaire below (a) and then assess your score using the scoring guide form (b).
a. Örebro musculoskeletal pain screening questionnaire - short-form (PDF 53KB)
b. Questionnaire scoring guide (PDF 15KB)
- If a score of > 50 is achieved, complete the ACC6273 Provider referral for pain management form.
ACC6273 Provider referral for pain management form (DOC 222KB)
- Submit both Orebro + ACC6273 to firstname.lastname@example.org.
- We will contact you to acknowledge receipt of the referral, liaise with ACC about the next steps for your client and keep you informed.