Physician Referral

Please use this easy to access form to send a secure email referral directly to Vitality Pain Center or your patients. We will confirm an appointment with you and your patient.


Referral to Commonwealth Pain Specialists, PLLC

** Once referral submitted, our office will contact you and patient**
  • If first time referral please fill out completely.
  • Patient Information

  • *Please fill out the form completely and submit button will send information to our office. If needed please fax a copy of the patient's most recent office notes and any recent imaging report, etc. to (502) 352-2534. If this is a workman's comp or MVA we will need that information and at least 48 hours notice to obtain proper approvals.