Request For Consultation



A place for non-surgical treatment of back and neck pain and other musculoskeletal issues.
Pain doesn’t need to be a constant part of your life. The team at MIPM strives to get to the root of your pain to help you feel better.

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Patients Information
Name
Address

Referral Information

Evaluate and Treat for Pain Management if necessary AND/OR Physical Therapy Evaluate and Treat if necessar
Claim Information
Type of Claim (Circle One):

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Attorney's Name:

Submit Referral • Fax: (651) 888-2611 • Email: admin@mipmclinics.com• Phone: (651) 433-7266

Please provide any related imaging if you have it, and first and last visit note with referral, if possible