Dr. Masami Hattori

Pain Management in San Francisco
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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 painrelief@drhattori.com

PATIENT NAME:_______________________________________________

CONTACT #: __________________________________________________

DIAGNOSIS: ___________________________________________________

 

REFERRING PHYSICIAN: ________________________________________

 

  • 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:  greater occipital nerve   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