5515 Utica Ridge Road, Suite #600 | Davenport, IA 52807 | P: 563.344.1050 | F: 563.424.4579

Forms

We are looking forward to meeting you. In order to get an appointment at PCI, P.C. we will need your previous notes and previous treatments of the pain condition in which you’re seeking relief. If you have a new injury coming from an Emergency Room, please make sure you sign a release and send your records via fax 563.424.4579 and please bring hard copy of your images if taken at that visit. If you are an athlete seeking our bio-regenerative relief therapy a referral is not necessary, please call for an appointment: 563.344.1050.

In Summary: If a referral is needed please have one faxed and obtain a hard copy of your x-ray or MRI image if performed. We will call you to schedule an appointment and direct you to our patient portal.

Required Forms

The portal will allow you to give your medical history, sign required forms and understand our philosophy.

There are 6 required forms to submit through the portal:

  • New Patient Paperwork
  • Notice of Privacy Policy
  • Protected Health Information PHI
  • Opioid philosophy
  • Opioid agreement (even if not taking)
  • Patient Financial Responsibility

As specialists we try to get everyone in quickly and by using this portal we obtain your personal information smoothly. If you have trouble using the portal please call the office 563.344.1050 or email scheduling@pcipain.com . If patients don’t complete their paperwork we will be forced to work someone in at your appointment time. We require all information to be received at our clinic 7 days prior to appointment.

As a courtesy we confirm all appointments electronically by phone 1-2 days prior to appointments.

We look forward to meeting you.

PCI, P.C. staff.