Pain Center Admission Forms

For your convenience and in order to expedite the admission process, we ask that you download the forms listed below, fill them out completely, and bring with you on your first appointment date.

Interventional Pain Management

If your assigned physician includes:

  • Dr. Laura Audell
  • Dr. Azita Far 
  • Dr. Viliam Furdik
  • Dr. Gene Lee
  • Dr. Yong-Jian Lin
  • Dr. James Nguyen
  • Dr. Gary Rosengarten
  • Dr. Howard Rosner
  • Dr. David Scott
  • Dr. Bahman Shamloo
  • Dr. Mary Alice Vijjeswarapu
  • Dr. Christopher Zarembinski

Please complete the Pain Evaluation Form and bring it with you.

Headache, Orofacial Pain and Sleep Apnea Program

If your assigned physician is either Dr. Alan Newman or Dr. Katayoun Omrani, please complete and bring the following forms with you:

The forms below should be substituted for the Head and Neck Evaluation Form if you are being seen for either of the following conditions:


If you are scheduled for a procedure, you may download instructions preparing you for sedation by reading: Procedure Scheduling and Instructions (PDF). This material should be read a minimum of six days prior to your procedure. You may also call 310-423-9600 to speak to a nurse regarding your procedure.