Midtown Manhattan
36 W 44th St Ste 914
New York, NY 10036
(212) 621-7746 Text Us BOOK ONLINE

*Immediate lab & testing results       *Same day appointments

This page was published on Feb 5, 2019, edited on Feb 5, 2019 by Dr. Melepura (Pain Management Doctor) of Sports Injury & Pain Management Clinic of New York

Patient Forms

Completing the proper medical forms, is necessary during your initial consultation with pain management New York specialist Dr. Melepura. Below, you may find links to our Patient Forms you may simply click on the desired form, print the form, complete each field, and bring these forms with you on the day of your scheduled appointment. We look forward to meeting you when you visit New York pain specialist Dr. Melepura of pain management clinic in NYC.

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Consent to Treatment
Notice of Privacy Practice
Email / Text Message Consent


In addition to bringing these completed forms to your initial appointment, also bring:

  • Any pertinent Medical Records, including any previous (if any) xrays and reports you may have had done
  • A list of current medications
  • Insurance Cards
  • Co-Payment – if your insurance company requires one, we are required by them to collect this payment at the time of service – You may pay by Visa/Mastercard credit or debit card or check


Our pain management clinic in New York works with most insurances and utilizes patients’ out-of-network benefits. For more information about the insurance coverage, patient forms or treatments offered at the NYC pain clinic please contact our Midtown office.


Sports Injury & Pain Management Clinic of New York
36 W 44th St Ste 1100
New York, NY 10036
(212) 621-7746
(Between 5th & 6th Ave)