{"id":1463,"date":"2025-04-04T06:35:18","date_gmt":"2025-04-04T06:35:18","guid":{"rendered":"https:\/\/shinglecreekmedicalgroup.com\/?page_id=1463"},"modified":"2025-07-07T17:52:04","modified_gmt":"2025-07-07T17:52:04","slug":"pain-referral-form","status":"publish","type":"page","link":"https:\/\/shinglecreekmedicalgroup.com\/?page_id=1463","title":{"rendered":""},"content":{"rendered":"\n<div class=\"wp-block-stackable-columns alignfull stk-block-columns stk-block stk-52f0d10 stk-block-background stk--has-background-overlay\" data-block-id=\"52f0d10\"><style>.stk-52f0d10 {background-color:#0a0806 !important;background-image:url(https:\/\/shinglecreekmedicalgroup.com\/wp-content\/uploads\/2025\/03\/Shingle-Creek-Consulting-Header.jpg) !important;background-attachment:fixed !important;padding-top:250px !important;padding-bottom:10px !important;margin-top:8px !important;margin-bottom:35px !important;top:-8px !important;bottom:100px !important;z-index:1 !important;transform:translateY(-4px) !important;}.stk-52f0d10:before{background-color:#0a0806 !important;opacity:0.7 !important;}.stk-52f0d10 > .stk-separator__top .stk-separator__wrapper{height:30px !important;}.stk-52f0d10-column{--stk-column-gap:0px !important;}@media screen and (max-width:999px){.stk-52f0d10 {padding-top:200px !important;padding-bottom:150px !important;}}<\/style><div class=\"stk-row stk-inner-blocks stk-block-content stk-content-align stk-52f0d10-column\">\n<div class=\"wp-block-stackable-column stk-block-column stk-column stk-block stk-76c1e59\" data-v=\"4\" data-block-id=\"76c1e59\"><div class=\"stk-column-wrapper stk-block-column__content stk-container stk-76c1e59-container stk--no-background stk--no-padding\"><div class=\"stk-block-content stk-inner-blocks stk-76c1e59-inner-blocks\">\n<div class=\"wp-block-stackable-heading stk-block-heading stk-block-heading--v2 stk-block stk-afeea05\" id=\"pain-referral-form\" data-block-id=\"afeea05\"><style>.stk-afeea05 .stk-block-heading__bottom-line{height:4px !important;}.stk-afeea05 {margin-bottom:15px !important;bottom:100px !important;}.stk-afeea05 .stk-block-heading__text{font-size:50px !important;color:var(u002du002dtheme-palette-color-8, #ffffff) !important;}@media screen and (max-width:999px){.stk-afeea05 .stk-block-heading__text{font-size:35px !important;}}<\/style><h1 class=\"stk-block-heading__text has-text-color has-palette-color-8-color has-text-align-center stk-block-heading--use-theme-margins\">Pain Referral Form<\/h1><\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n<\/div><\/div><\/div>\n<\/div><\/div>\n\n\n\n<div style=\"height:43px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading has-text-align-center\" id=\"mri-referral-submit-fill-online\">MRI Referral \u2013 Submit &amp; Fill Online<\/h2>\n\n\n\n<!DOCTYPE html>\n<html lang=\"en\">\n<head>\n    <meta charset=\"UTF-8\">\n    <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n    <title>Pain Management Referral Form &#8211; Shingle Creek Medical Group<\/title>\n    <script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/jspdf\/2.5.1\/jspdf.umd.min.js\"><\/script>\n    <script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/html2canvas\/1.4.1\/html2canvas.min.js\"><\/script>\n    <style>\n        * {\n            margin: 0;\n            padding: 0;\n            box-sizing: border-box;\n        }\n        \n        body {\n            font-family: Arial, sans-serif;\n            background-color: transparent;\n            padding: 0;\n            margin: 0;\n        }\n        \n        .form-container {\n            max-width: 1200px;\n            margin: 0 auto;\n            background-color: transparent;\n            padding: 0;\n        }\n        \n        .form-wrapper {\n            background-color: white;\n            padding: 40px;\n            box-shadow: 0 0 10px rgba(0,0,0,0.1);\n            margin-top: 20px;\n        }\n        \n        .form-header {\n            text-align: center;\n            margin-bottom: 30px;\n            border-bottom: 2px solid #000;\n            padding-bottom: 20px;\n        }\n        \n        .form-header h1 {\n            font-size: 24px;\n            margin-bottom: 10px;\n        }\n        \n        .form-header p {\n            font-size: 14px;\n            margin-bottom: 5px;\n        }\n        \n        .form-row {\n            display: flex;\n            gap: 20px;\n            margin-bottom: 15px;\n            flex-wrap: wrap;\n        }\n        \n        .form-group {\n            flex: 1;\n            min-width: 250px;\n        }\n        \n        .form-group.full-width {\n            flex: 1 1 100%;\n        }\n        \n        label {\n            font-weight: bold;\n            display: inline-block;\n            margin-bottom: 5px;\n            font-size: 14px;\n        }\n        \n        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  input[type=\"radio\"] {\n                margin-right: 3px;\n                width: 10px;\n                height: 10px;\n            }\n            \n            label {\n                font-size: 11px;\n                margin-bottom: 2px;\n            }\n            \n            .section-title {\n                font-size: 12px;\n                padding: 5px;\n                margin: 10px 0 8px 0;\n                background-color: #000 !important;\n                color: white !important;\n                -webkit-print-color-adjust: exact;\n                print-color-adjust: exact;\n            }\n            \n            .treatment-grid {\n                grid-template-columns: repeat(4, 1fr);\n                gap: 10px;\n                margin-bottom: 10px;\n                page-break-inside: avoid;\n            }\n            \n            .treatment-section {\n                padding: 8px;\n                border: 1px solid #000;\n                page-break-inside: avoid;\n            }\n            \n            .treatment-section h3 {\n                font-size: 11px;\n                margin-bottom: 5px;\n            }\n            \n            .location-inputs input {\n                margin-bottom: 2px;\n                font-size: 10px;\n                height: 16px;\n            }\n            \n            .trauma-checkboxes {\n                grid-template-columns: repeat(3, 1fr);\n                gap: 5px;\n                margin-bottom: 10px;\n                page-break-inside: avoid;\n            }\n            \n            .trauma-checkboxes label {\n                font-size: 10px;\n            }\n            \n            .checkbox-group {\n                gap: 10px;\n                margin-top: 2px;\n            }\n            \n            .checkbox-group label {\n                font-size: 10px;\n            }\n            \n            \/* Ensure single page layout *\/\n            .form-container {\n                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.trauma-checkboxes {\n                grid-template-columns: repeat(2, 1fr);\n            }\n        }\n        \n        @media (max-width: 600px) {\n            .form-container {\n                padding: 20px;\n            }\n            \n            .form-row {\n                flex-direction: column;\n            }\n            \n            .form-group {\n                min-width: 100%;\n            }\n            \n            .trauma-checkboxes {\n                grid-template-columns: 1fr;\n            }\n        }\n    <\/style>\n<\/head>\n<body>\n    <div class=\"form-container\" id=\"referralForm\">\n        <div class=\"form-wrapper\">\n            <div class=\"form-header\">\n                <h1>Shingle Creek Medical Group, LLC<\/h1>\n                <p>2781 Freeway Blvd, Suite 160, Brooklyn Center, MN 55430<\/p>\n                <p>763.244.8022 \u25cf (F) 763.244.8021<\/p>\n                <p>scheduling@shinglecreekmedicalgroup.com<\/p>\n                <p>www.shinglecreekmedicalgroup.com<\/p>\n            <\/div>\n        \n        <form id=\"painReferralForm\">\n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"patientName\">Patient Name:<\/label>\n                    <input type=\"text\" id=\"patientName\" name=\"patientName\" required>\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"phone\">Phone:<\/label>\n                    <input type=\"tel\" id=\"phone\" name=\"phone\" required>\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"dob\">DOB:<\/label>\n                    <input type=\"date\" id=\"dob\" name=\"dob\" required>\n                <\/div>\n                <div class=\"form-group\">\n                    <label>Gender:<\/label>\n                    <div class=\"checkbox-group\">\n                        <label><input type=\"radio\" name=\"gender\" value=\"Male\"> Male<\/label>\n                        <label><input type=\"radio\" name=\"gender\" value=\"Female\"> Female<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"referringPhysician\">Referring Physician:<\/label>\n                    <input type=\"text\" id=\"referringPhysician\" name=\"referringPhysician\">\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"physicianPhone\">Phone #:<\/label>\n                    <input type=\"tel\" id=\"physicianPhone\" name=\"physicianPhone\">\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"fax\">Fax:<\/label>\n                    <input type=\"tel\" id=\"fax\" name=\"fax\">\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"email\">Email:<\/label>\n                    <input type=\"email\" id=\"email\" name=\"email\">\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-row\">\n                <div class=\"form-group full-width\">\n                    <label for=\"workingDiagnosis\">Working Diagnosis: ICD<\/label>\n                    <input type=\"text\" id=\"workingDiagnosis\" name=\"workingDiagnosis\">\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"attorney\">Attorney:<\/label>\n                    <input type=\"text\" id=\"attorney\" name=\"attorney\">\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"attorneyPhone\">Phone:<\/label>\n                    <input type=\"tel\" id=\"attorneyPhone\" name=\"attorneyPhone\">\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"insuranceCompany\">Insurance Company:<\/label>\n                    <input type=\"text\" id=\"insuranceCompany\" name=\"insuranceCompany\">\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"claimNumber\">Claim Number\/ID:<\/label>\n                    <input type=\"text\" id=\"claimNumber\" name=\"claimNumber\">\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"adjuster\">Adjuster:<\/label>\n                    <input type=\"text\" id=\"adjuster\" name=\"adjuster\">\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"adjusterPhone\">Phone:<\/label>\n                    <input type=\"tel\" id=\"adjusterPhone\" name=\"adjusterPhone\">\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"formDate\">Date:<\/label>\n                    <input type=\"date\" id=\"formDate\" name=\"formDate\" required>\n                <\/div>\n            <\/div>\n            \n            <div class=\"section-title\">PAIN MANAGEMENT AND OTHER TREATMENT<\/div>\n            \n            <div class=\"treatment-grid\">\n                <div class=\"treatment-section\">\n                    <h3>CONSULTATION<\/h3>\n                    <label><input type=\"checkbox\" name=\"consultationOnly\"> Consultation Only<\/label><br>\n                    <label><input type=\"checkbox\" name=\"consultAndTreat\"> Consult &#038; Treat<\/label>\n                <\/div>\n                \n                <div class=\"treatment-section\">\n                    <h3>Trigger Point Injection<\/h3>\n                    <p style=\"font-size: 11px; margin-bottom: 5px;\">Location\/s:<\/p>\n                    <div class=\"location-inputs\">\n                        <input type=\"text\" name=\"triggerPoint1\" placeholder=\"Location 1\">\n                        <input type=\"text\" name=\"triggerPoint2\" placeholder=\"Location 2\">\n                        <input type=\"text\" name=\"triggerPoint3\" placeholder=\"Location 3\">\n                        <input type=\"text\" name=\"triggerPoint4\" placeholder=\"Location 4\">\n                        <input type=\"text\" name=\"triggerPoint5\" placeholder=\"Location 5\">\n                    <\/div>\n                <\/div>\n                \n                <div class=\"treatment-section\">\n                    <h3>Joint Injection<\/h3>\n                    <p style=\"font-size: 11px; margin-bottom: 5px;\">Location\/s:<\/p>\n                    <div class=\"location-inputs\">\n                        <input type=\"text\" name=\"jointInjection1\" placeholder=\"Location 1\">\n                        <input type=\"text\" name=\"jointInjection2\" placeholder=\"Location 2\">\n                        <input type=\"text\" name=\"jointInjection3\" placeholder=\"Location 3\">\n                        <input type=\"text\" name=\"jointInjection4\" placeholder=\"Location 4\">\n                        <input type=\"text\" name=\"jointInjection5\" placeholder=\"Location 5\">\n                    <\/div>\n                <\/div>\n                \n                <div class=\"treatment-section\">\n                    <h3>PRP (Platelet-Rich Plasma)<\/h3>\n                    <p style=\"font-size: 11px; margin-bottom: 5px;\">Location\/s:<\/p>\n                    <div class=\"location-inputs\">\n                        <input type=\"text\" name=\"prp1\" placeholder=\"Location 1\">\n                        <input type=\"text\" name=\"prp2\" placeholder=\"Location 2\">\n                        <input type=\"text\" name=\"prp3\" placeholder=\"Location 3\">\n                        <input type=\"text\" name=\"prp4\" placeholder=\"Location 4\">\n                        <input type=\"text\" name=\"prp5\" placeholder=\"Location 5\">\n                    <\/div>\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-group full-width\">\n                <label for=\"reasonForVisit\">Reason For Visit:<\/label>\n                <textarea id=\"reasonForVisit\" name=\"reasonForVisit\" rows=\"2\"><\/textarea>\n            <\/div>\n            \n            <div class=\"section-title\">TYPE OF TRAUMA<\/div>\n            \n            <div class=\"trauma-checkboxes\">\n                <label><input type=\"checkbox\" name=\"neckPain\"> Neck Pain<\/label>\n                <label><input type=\"checkbox\" name=\"lumbarPain\"> Lumbar Pain<\/label>\n                <label><input type=\"checkbox\" name=\"autoInjury\"> Auto Injury<\/label>\n                <label><input type=\"checkbox\" name=\"thoracicPain\"> Thoracic Pain<\/label>\n                <label><input type=\"checkbox\" name=\"headacheDizziness\"> Headache\/Dizziness<\/label>\n                <label><input type=\"checkbox\" name=\"decreasedROM\"> Decreased ROM<\/label>\n                <label><input type=\"checkbox\" name=\"armTingling\"> Arm Tingling\/Numbness\/Pain<\/label>\n                <label><input type=\"checkbox\" name=\"muscleSpasm\"> Muscle Spasm<\/label>\n                <label><input type=\"checkbox\" name=\"sciatica\"> Sciatica\/Leg Tingling\/Numbness\/Pain<\/label>\n                <label><input type=\"checkbox\" name=\"other\"> OTHER: <input type=\"text\" name=\"otherTrauma\" style=\"width: 120px; margin-left: 5px;\"><\/label>\n            <\/div>\n            \n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"dateOfTrauma\">Date of Trauma:<\/label>\n                    <input type=\"date\" id=\"dateOfTrauma\" name=\"dateOfTrauma\">\n                <\/div>\n                <div class=\"form-group\">\n                    <label>History of surgery\/malignancy:<\/label>\n                    <div class=\"checkbox-group\">\n                        <label><input type=\"radio\" name=\"surgeryHistory\" value=\"YES\"> YES<\/label>\n                        <label><input type=\"radio\" name=\"surgeryHistory\" value=\"NO\"> NO<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n            \n            <div class=\"form-group full-width\">\n                <label for=\"physicianSignature\">Physician Signature:<\/label>\n                <input type=\"text\" id=\"physicianSignature\" name=\"physicianSignature\" placeholder=\"Type physician name\">\n            <\/div>\n            \n            <div class=\"button-group\">\n                <button type=\"button\" class=\"btn-primary\" onclick=\"downloadPDF()\">Download as PDF<\/button>\n                <button type=\"button\" class=\"btn-secondary\" onclick=\"printForm()\">Print Form<\/button>\n                <button type=\"button\" class=\"btn-success\" onclick=\"emailForm()\">Email Form<\/button>\n            <\/div>\n        <\/form>\n        <\/div>\n    <\/div>\n    \n    <script>\n        \/\/ Set today's date as default for form date\n        document.getElementById('formDate').valueAsDate = new Date();\n        \n        function downloadPDF() {\n            const { jsPDF } = window.jspdf;\n            const doc = new jsPDF();\n            \n            \/\/ Get form data\n            const formData = new FormData(document.getElementById('painReferralForm'));\n            \n            \/\/ Add header\n            doc.setFontSize(16);\n            doc.setFont(undefined, 'bold');\n            doc.text('Shingle Creek Medical Group, LLC', 105, 20, { align: 'center' });\n            doc.setFont(undefined, 'normal');\n            doc.setFontSize(10);\n            doc.text('2781 Freeway Blvd, Suite 160, Brooklyn Center, MN 55430', 105, 28, { align: 'center' });\n            doc.text('763.244.8022 \u2022 (F) 763.244.8021', 105, 34, { align: 'center' });\n            doc.text('scheduling@shinglecreekmedicalgroup.com', 105, 40, { align: 'center' });\n            \n            \/\/ Add form content\n            let y = 55;\n            doc.setFontSize(11);\n            \n            \/\/ Patient Information - Row 1\n            doc.setFont(undefined, 'bold');\n            doc.text('Patient Name:', 20, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('patientName') || '', 50, y);\n            \n            doc.setFont(undefined, 'bold');\n            doc.text('Phone:', 120, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('phone') || '', 135, y);\n            y += 8;\n            \n            \/\/ Row 2\n            doc.setFont(undefined, 'bold');\n            doc.text('DOB:', 20, y);\n      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doc.text(formData.get('fax') || '', 31, y);\n            \n            doc.setFont(undefined, 'bold');\n            doc.text('Email:', 120, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('email') || '', 135, y);\n            y += 8;\n            \n            \/\/ Working Diagnosis\n            doc.setFont(undefined, 'bold');\n            doc.text('Working Diagnosis: ICD', 20, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('workingDiagnosis') || '', 70, y);\n            y += 8;\n            \n            \/\/ Attorney row\n            doc.setFont(undefined, 'bold');\n            doc.text('Attorney:', 20, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('attorney') || '', 40, y);\n            \n            doc.setFont(undefined, 'bold');\n            doc.text('Phone:', 120, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('attorneyPhone') || '', 135, y);\n            y += 8;\n            \n            \/\/ Insurance\n            doc.setFont(undefined, 'bold');\n            doc.text('Insurance Company:', 20, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('insuranceCompany') || '', 60, y);\n            \n            doc.setFont(undefined, 'bold');\n            doc.text('Claim Number\/ID:', 120, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('claimNumber') || '', 155, y);\n            y += 8;\n            \n            \/\/ Adjuster\n            doc.setFont(undefined, 'bold');\n            doc.text('Adjuster:', 20, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('adjuster') || '', 40, y);\n            \n            doc.setFont(undefined, 'bold');\n            doc.text('Phone:', 120, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('adjusterPhone') || '', 135, y);\n            y += 8;\n            \n            \/\/ Date\n            doc.setFont(undefined, 'bold');\n            doc.text('Date:', 20, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('formDate') || '', 33, y);\n            y += 15;\n            \n            \/\/ Treatment section header\n            doc.setFontSize(12);\n            doc.setFillColor(0, 0, 0);\n            doc.rect(20, y, 170, 8, 'F');\n            doc.setTextColor(255, 255, 255);\n            doc.setFont(undefined, 'bold');\n            doc.text('PAIN MANAGEMENT AND OTHER TREATMENT', 105, y + 6, { align: 'center' });\n            doc.setTextColor(0, 0, 0);\n            doc.setFont(undefined, 'normal');\n            y += 15;\n            \n            doc.setFontSize(10);\n            \n            \/\/ Create treatment section in columns\n            const startY = y;\n            \n            \/\/ Column 1: Consultation\n            doc.setFont(undefined, 'bold');\n            doc.text('CONSULTATION:', 20, y);\n            doc.setFont(undefined, 'normal');\n            y += 6;\n            doc.rect(20, y - 3, 3, 3);\n            if (formData.get('consultationOnly')) {\n                doc.text('X', 20.5, y - 0.5);\n            }\n            doc.text('Consultation Only', 26, y);\n            y += 6;\n            doc.rect(20, y - 3, 3, 3);\n            if (formData.get('consultAndTreat')) {\n                doc.text('X', 20.5, y - 0.5);\n            }\n            doc.text('Consult & Treat', 26, y);\n            \n            \/\/ Column 2: Trigger Points\n            y = startY;\n            doc.setFont(undefined, 'bold');\n            doc.text('Trigger Point Injections:', 65, y);\n            doc.setFont(undefined, 'normal');\n            doc.text('Location\/s:', 65, y + 6);\n            let triggerY = y + 12;\n            for (let i = 1; i <= 5; i++) {\n                const location = formData.get(`triggerPoint${i}`);\n                if (location) {\n                    doc.text(location, 65, triggerY);\n                    triggerY += 5;\n                }\n            }\n            \n            \/\/ Column 3: Joint Injections\n            y = startY;\n            doc.setFont(undefined, 'bold');\n            doc.text('Joint Injections:', 115, y);\n            doc.setFont(undefined, 'normal');\n            doc.text('Location\/s:', 115, y + 6);\n            let jointY = y + 12;\n            for (let i = 1; i <= 5; i++) {\n                const location = formData.get(`jointInjection${i}`);\n                if (location) {\n                    doc.text(location, 115, jointY);\n                    jointY += 5;\n                }\n            }\n            \n            \/\/ Column 4: PRP\n            y = startY;\n            doc.setFont(undefined, 'bold');\n            doc.text('PRP (Platelet-Rich Plasma):', 155, y);\n            doc.setFont(undefined, 'normal');\n            doc.text('Location\/s:', 155, y + 6);\n            let prpY = y + 12;\n            for (let i = 1; i <= 5; i++) {\n                const location = formData.get(`prp${i}`);\n                if (location) {\n                    doc.text(location, 155, prpY);\n                    prpY += 5;\n                }\n            }\n            \n            \/\/ Move to next section\n            y = Math.max(triggerY, jointY, prpY, y + 40) + 10;\n            \n            \/\/ Reason for visit\n            doc.setFont(undefined, 'bold');\n            doc.text('Reason For Visit:', 20, y);\n            doc.setFont(undefined, 'normal');\n            y += 6;\n            const reasonText = formData.get('reasonForVisit') || '';\n            const splitReason = doc.splitTextToSize(reasonText, 170);\n            doc.text(splitReason, 20, y);\n            y += splitReason.length * 5 + 10;\n            \n            \/\/ Type of Trauma header\n            doc.setFontSize(12);\n            doc.setFillColor(0, 0, 0);\n            doc.rect(20, y, 170, 8, 'F');\n            doc.setTextColor(255, 255, 255);\n            doc.setFont(undefined, 'bold');\n            doc.text('TYPE OF TRAUMA', 105, y + 6, { align: 'center' });\n            doc.setTextColor(0, 0, 0);\n            doc.setFont(undefined, 'normal');\n            y += 15;\n            \n            doc.setFontSize(10);\n            \n            \/\/ Trauma checkboxes in 3 columns\n            const traumaTypes = [\n                { field: 'neckPain', label: 'Neck Pain' },\n                { field: 'lumbarPain', label: 'Lumbar Pain' },\n                { field: 'autoInjury', label: 'Auto Injury' },\n                { field: 'thoracicPain', label: 'Thoracic Pain' },\n                { field: 'headacheDizziness', label: 'Headache\/Dizziness' },\n                { field: 'decreasedROM', label: 'Decreased ROM' },\n                { field: 'armTingling', label: 'Arm Tingling\/Numbness\/Pain' },\n                { field: 'muscleSpasm', label: 'Muscle Spasm' },\n                { field: 'sciatica', label: 'Sciatica\/Leg Tingling\/Numbness\/Pain' }\n            ];\n            \n            let traumaX = 20;\n            let traumaY = y;\n            let columnCount = 0;\n            \n            traumaTypes.forEach((trauma, index) => {\n                if (columnCount >= 3) {\n                    traumaY += 6;\n                    traumaX = 20;\n                    columnCount = 0;\n                }\n                \n                \/\/ Draw checkbox\n                doc.rect(traumaX, traumaY - 3, 3, 3);\n                if (formData.get(trauma.field)) {\n                    doc.text('X', traumaX + 0.5, traumaY - 0.5);\n                }\n                doc.text(trauma.label, traumaX + 6, traumaY);\n                \n                traumaX += 62;\n                columnCount++;\n            });\n            \n            \/\/ Other trauma\n            traumaY += 6;\n            doc.rect(20, traumaY - 3, 3, 3);\n            if (formData.get('other')) {\n                doc.text('X', 20.5, traumaY - 0.5);\n            }\n            doc.text('OTHER: ', 26, traumaY);\n            doc.text(formData.get('otherTrauma') || '', 45, traumaY);\n            \n            y = traumaY + 15;\n            \n            \/\/ Bottom section\n            doc.setFont(undefined, 'bold');\n            doc.text('Date of Trauma:', 20, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('dateOfTrauma') || '', 55, y);\n            \n            doc.setFont(undefined, 'bold');\n            doc.text('History of surgery\/malignancy:', 100, y);\n            doc.setFont(undefined, 'normal');\n            \n            \/\/ Draw YES\/NO checkboxes\n            const xPos = 160;\n            doc.rect(xPos, y - 3, 3, 3);\n            if (formData.get('surgeryHistory') === 'YES') {\n                doc.text('X', xPos + 0.5, y - 0.5);\n            }\n            doc.text('YES', xPos + 6, y);\n            \n            doc.rect(xPos + 20, y - 3, 3, 3);\n            if (formData.get('surgeryHistory') === 'NO') {\n                doc.text('X', xPos + 20.5, y - 0.5);\n            }\n            doc.text('NO', xPos + 26, y);\n            \n            y += 10;\n            \n            \/\/ Physician signature\n            doc.setFont(undefined, 'bold');\n            doc.text('Physician Signature:', 20, y);\n            doc.setFont(undefined, 'normal');\n            doc.text(formData.get('physicianSignature') || '', 60, y);\n            \n            \/\/ Save the PDF\n            doc.save('pain-referral-form.pdf');\n        }\n        \n        function printForm() {\n            window.print();\n        }\n        \n        function emailForm() {\n            \/\/ Collect form data\n            const form = document.getElementById('painReferralForm');\n            const formData = new FormData(form);\n            \n            let emailBody = 'Pain Management Referral Form\\n\\n';\n            emailBody += '=================================\\n\\n';\n            \n            \/\/ Patient Information\n            emailBody += 'PATIENT INFORMATION\\n';\n            emailBody += `Patient Name: ${formData.get('patientName') || ''}\\n`;\n            emailBody += `Phone: ${formData.get('phone') || ''}\\n`;\n            emailBody += `DOB: ${formData.get('dob') || ''}\\n`;\n            emailBody += `Gender: ${formData.get('gender') || ''}\\n\\n`;\n            \n            \/\/ Physician Information\n            emailBody += 'REFERRING PHYSICIAN INFORMATION\\n';\n            emailBody += `Referring Physician: ${formData.get('referringPhysician') || ''}\\n`;\n            emailBody += `Phone: ${formData.get('physicianPhone') || ''}\\n`;\n            emailBody += `Fax: ${formData.get('fax') || ''}\\n`;\n            emailBody += `Email: ${formData.get('email') || ''}\\n\\n`;\n            \n            \/\/ Diagnosis\n            emailBody += `Working Diagnosis ICD: ${formData.get('workingDiagnosis') || ''}\\n\\n`;\n            \n            \/\/ Legal\/Insurance Information\n            emailBody += 'LEGAL\/INSURANCE INFORMATION\\n';\n            emailBody += `Attorney: ${formData.get('attorney') || ''}\\n`;\n            emailBody += `Attorney Phone: ${formData.get('attorneyPhone') || ''}\\n`;\n            emailBody += `Insurance Company: ${formData.get('insuranceCompany') || ''}\\n`;\n            emailBody += `Claim Number\/ID: ${formData.get('claimNumber') || ''}\\n`;\n            emailBody += `Adjuster: ${formData.get('adjuster') || ''}\\n`;\n            emailBody += `Adjuster Phone: ${formData.get('adjusterPhone') || ''}\\n\\n`;\n            \n            emailBody += `Form Date: ${formData.get('formDate') || ''}\\n\\n`;\n            \n            \/\/ Treatment Options\n            emailBody += 'PAIN MANAGEMENT AND OTHER TREATMENT\\n';\n            emailBody += 'Consultation:\\n';\n            if (formData.get('consultationOnly')) emailBody += '  \u2713 Consultation Only\\n';\n            if (formData.get('consultAndTreat')) emailBody += '  \u2713 Consult & Treat\\n';\n            emailBody += '\\n';\n            \n            \/\/ Trigger Points\n            emailBody += 'Trigger Point Injections:\\n';\n            for (let i = 1; i <= 5; i++) {\n                const location = formData.get(`triggerPoint${i}`);\n                if (location) emailBody += `  - ${location}\\n`;\n            }\n            emailBody += '\\n';\n            \n            \/\/ Joint Injections\n            emailBody += 'Joint Injections:\\n';\n            for (let i = 1; i <= 5; i++) {\n                const location = formData.get(`jointInjection${i}`);\n                if (location) emailBody += `  - ${location}\\n`;\n            }\n            emailBody += '\\n';\n            \n            \/\/ PRP\n            emailBody += 'PRP (Platelet-Rich Plasma):\\n';\n            for (let i = 1; i <= 5; i++) {\n                const location = formData.get(`prp${i}`);\n                if (location) emailBody += `  - ${location}\\n`;\n            }\n            emailBody += '\\n';\n            \n            \/\/ Reason for visit\n            emailBody += `Reason for Visit: ${formData.get('reasonForVisit') || ''}\\n\\n`;\n            \n            \/\/ Type of Trauma\n            emailBody += 'TYPE OF TRAUMA\\n';\n            if (formData.get('neckPain')) emailBody += '  \u2713 Neck Pain\\n';\n            if (formData.get('lumbarPain')) emailBody += '  \u2713 Lumbar Pain\\n';\n            if (formData.get('autoInjury')) emailBody += '  \u2713 Auto Injury\\n';\n            if (formData.get('thoracicPain')) emailBody += '  \u2713 Thoracic Pain\\n';\n            if (formData.get('headacheDizziness')) emailBody += '  \u2713 Headache\/Dizziness\\n';\n            if (formData.get('decreasedROM')) emailBody += '  \u2713 Decreased ROM\\n';\n            if (formData.get('armTingling')) emailBody += '  \u2713 Arm Tingling\/Numbness\/Pain\\n';\n            if (formData.get('muscleSpasm')) emailBody += '  \u2713 Muscle Spasm\\n';\n            if (formData.get('sciatica')) emailBody += '  \u2713 Sciatica\/Leg Tingling\/Numbness\/Pain\\n';\n            if (formData.get('other')) emailBody += `  \u2713 OTHER: ${formData.get('otherTrauma') || ''}\\n`;\n            emailBody += '\\n';\n            \n            emailBody += `Date of Trauma: ${formData.get('dateOfTrauma') || ''}\\n`;\n            emailBody += `History of surgery\/malignancy: ${formData.get('surgeryHistory') || ''}\\n\\n`;\n            \n            emailBody += `Physician Signature: ${formData.get('physicianSignature') || ''}\\n`;\n            \n            \/\/ Create mailto link\n            const subject = encodeURIComponent('Pain Management Referral Form');\n            const body = encodeURIComponent(emailBody);\n            const mailtoLink = `mailto:scheduling@shinglecreekmedicalgroup.com?subject=${subject}&#038;body=${body}`;\n            \n            \/\/ Open email client\n            window.location.href = mailtoLink;\n        }\n    <\/script>\n<\/body>\n<\/html>\n\n\n\n<div style=\"height:134px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-stackable-divider stk-block-divider stk-block stk-dd0dcaa is-style-bar\" data-block-id=\"dd0dcaa\"><style>.stk-dd0dcaa hr.stk-block-divider__hr{background:#a8a8a8 !important;width:88% !important;}<\/style><hr class=\"stk-block-divider__hr\"\/><\/div>\n\n\n\n<h2 class=\"wp-block-heading has-text-align-center\" id=\"mri-referral-submit-fill-online\">Download PDF Form Below<\/h2>\n\n\n\n<section class=\"wp-block-greenshift-blocks-row alignfull gspb_row gspb_row-id-gsbp-70559a9\" id=\"gspb_row-id-gsbp-70559a9\"><div class=\"gspb_row__content\">  <\/div><\/section>\n\n\n\n<section class=\"wp-block-greenshift-blocks-row alignfull gspb_row gspb_row-id-gsbp-f48270f\" id=\"gspb_row-id-gsbp-f48270f\"><div class=\"gspb_row__content\">  <\/div><\/section>\n\n\n\n<section class=\"wp-block-greenshift-blocks-row alignfull gspb_row gspb_row-id-gsbp-583e05f\" id=\"gspb_row-id-gsbp-583e05f\"><div class=\"gspb_row__content\">  <\/div><\/section>\n\n\n\n<section class=\"wp-block-greenshift-blocks-row alignfull gspb_row gspb_row-id-gsbp-f1a03bd\" id=\"gspb_row-id-gsbp-f1a03bd\"><div class=\"gspb_row__content\"> \n<div class=\"wp-block-greenshift-blocks-row-column gspb_row__col--12 gspb_col-id-gsbp-9b97bc5\" id=\"gspb_col-id-gsbp-9b97bc5\">\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-995f960e wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div class=\"wp-block-pdfemb-pdf-embedder-viewer\"><a href=\"https:\/\/shinglecreekmedicalgroup.com\/wp-content\/uploads\/2025\/04\/SCMG-Pain-Referral-Form.pdf\" class=\"pdfemb-viewer\" style=\"\" data-width=\"max\" data-height=\"max\" data-toolbar=\"bottom\" data-toolbar-fixed=\"off\">SCMG-Pain-Referral-Form<\/a><\/div><\/div>\n<\/div>\n<\/div>\n <\/div><\/section>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">* NOTE: This form does require the latest version of Adobe Reader. <a href=\"https:\/\/get.adobe.com\/reader\/\" target=\"_blank\" rel=\"noreferrer noopener\">Download Adobe Reader here.<\/a><br>You may fill out the form and save it and\/or print it and fax it to us: 763.244.8021<\/p>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-995f960e wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n<\/div>\n<\/div>\n\n\n\n<section class=\"wp-block-greenshift-blocks-row alignfull gspb_row gspb_row-id-gsbp-69bfc6e\" id=\"gspb_row-id-gsbp-69bfc6e\"><div class=\"gspb_row__content\"> \n<div class=\"wp-block-greenshift-blocks-row-column gspb_row__col--12 gspb_col-id-gsbp-3ed2382\" id=\"gspb_col-id-gsbp-3ed2382\">\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-995f960e wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<section class=\"wp-block-greenshift-blocks-row alignfull gspb_row gspb_row-id-gsbp-a5e6168\" id=\"gspb_row-id-gsbp-a5e6168\"><div class=\"gspb_row__content\"> \n<div class=\"wp-block-greenshift-blocks-row-column gspb_row__col--12 gspb_col-id-gsbp-5abe282\" id=\"gspb_col-id-gsbp-5abe282\">\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-995f960e wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-995f960e wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n <\/div><\/section>\n<\/div>\n<\/div>\n<\/div>\n <\/div><\/section>\n\n\n\n<section class=\"wp-block-greenshift-blocks-row alignfull gspb_row gspb_row-id-gsbp-946bd1a\" id=\"gspb_row-id-gsbp-946bd1a\"><div class=\"gspb_row__content\"> \n<div class=\"wp-block-greenshift-blocks-row-column gspb_row__col--12 gspb_col-id-gsbp-377e6bb\" id=\"gspb_col-id-gsbp-377e6bb\"><\/div>\n <\/div><\/section>\n","protected":false},"excerpt":{"rendered":"<p>Pain Referral Form MRI Referral \u2013 Submit &amp; Fill Online Pain Management Referral Form &#8211; Shingle Creek Medical Group Shingle Creek Medical Group, LLC 2781 Freeway Blvd, Suite 160, Brooklyn Center, MN 55430 763.244.8022 \u25cf (F) 763.244.8021 scheduling@shinglecreekmedicalgroup.com www.shinglecreekmedicalgroup.com Patient Name: Phone: DOB: Gender: Male Female Referring Physician: Phone #: Fax: Email: Working Diagnosis: ICD [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"bBlocksCursorData":"","_gspb_post_css":"#gspb_row-id-gsbp-70559a9,#gspb_row-id-gsbp-f48270f{justify-content:space-between;margin-top:0;display:flex;flex-wrap:wrap;margin-bottom:0}#gspb_row-id-gsbp-583e05f>.gspb_row__content,#gspb_row-id-gsbp-70559a9>.gspb_row__content,#gspb_row-id-gsbp-f1a03bd>.gspb_row__content,#gspb_row-id-gsbp-f48270f>.gspb_row__content{display:flex;justify-content:space-between;margin:0 auto;width:100%;flex-wrap:wrap}.gspb_row{position:relative}div[id^=gspb_col-id]{box-sizing:border-box;position:relative;padding:var(--gs-row-column-padding, 15px min(3vw, 20px))}body.gspb-bodyfront #gspb_row-id-gsbp-70559a9>.gspb_row__content,body.gspb-bodyfront #gspb_row-id-gsbp-f48270f>.gspb_row__content{width:var(--theme-container-width, 1200px);max-width:var(--theme-normal-container-max-width, 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