Pain Management Consult Request:
Dr Masami Hattori
1700 California St Ste 340, San Francisco CA 94107          (cross street Van Ness Ave)
Phone: 415.292.9756

www.drhattori.com

Please fax to (415)673-0516 or email to appointment@drhattori.com

PATIENT NAME:__________________________________


CONTACT #:

________________________________________________


DIAGNOSIS:

_________________________________________________

We accept:

Aetna

Blue Shields/Blue Cross

Brown and Toland

Cigna

Healthnet

Hills Physician

Medicare

United Health Care

Workers Compensation

•  Consult: evaluate and manage

•  
   Epidural Steroid injection: 
         level ______________________________

• Facet Injection:
         level _______________________________

• Facet Rhizotomy:
         level ______________________________

• Spinal Cord stimulator trial/ implant

• Intrathecal pump trial/ implant

• Sympathetic block:    
         stellate ganglion      lumbar       hypogastric

• Peripheral nerve block: 
         ilioinguinal   pudendal nerve

• Neurolysis:  celiac plexus block

• Joint injection:  
         finger  wrist  elbow   shoulder   hip   knee  ankle  toes

• Trigger Point injection

• Botox injection

• Opioid Detox/ Suboxone:  
         Inpatient     Outpatient