APPLICATION FOR EXCELLENCE IN PAIN PRACTICE
BY A PAIN CENTER

 

All Input Fields Are Required Unless So Noted As Optional.

Registration Date:
Name of Pain Center:
Address Line 1:
Address Line 2:  Optional
Address Line 3:  Optional
City:
State/Province:
Postal Code:
Country:
Your WIP Section:
Telephone:
FAX:  Optional
Email:
Web Site:   Optional (EX: www.domain.com)
Type of Pain Center  (Choose One Type Only)    Academic       Private       Multidisciplinary 
Is your pain center affiliated with a hospital or university?   

If YES, what is the name of the hospital or university:
   YES       NO      


Number of Working Hours per week:    (10)       (20)       (30)  (40)       more than (40) 
Director Name:
Board Certified or equivalent:  Optional   (FIPP-Pain Management-Equivalent in your country)
Contact person (Surname/Name):    Position:  
Physician Specialists: (check all that apply) Anesthesiology      
Neurology      
Orthopedic Surgery      
Medicine      
General Surgery 
Psychiatry       
Neurosurgery      
Oncology      
Other    Specify  
 
Other Personnel: (check all that apply) Administrative Manager      
Nurse       
Physical Therapy/ Occupational Therapy      
Psychologist       
Other    Specify  
 
Strengths of your Pain Center (Type of clinical practice, for example - check all that apply) Pain Fellowship Training Center   (Accredited?  Yes  No)    
Failed back and neck surgery      
RSD - CRPS      
Headache      
Neuropathic Pain 
Cancer Pain      
Other    Specify  
 
Training and Education: (check all that apply) Fellowship      
Visiting physicians      
Structure comprehensive Lectures      
Multidisciplinary Evaluation      
Specialized Training Program 
Comprehensive Care      
 
Willing to share experience or provide consultation in: (check all that apply) Pharmacological Management      
Interventional Techniques      
Behavioral Management      
Physical Therapy/ Occupational Therapy      
Palliative Care 
Research      
Other    Specify  
Total number of new patients seen at your Center per year:  
Total number of follow-up visits per year:  
Total number of specialty care visits provided per year:  
 
Distinguishing Characteristics of your Pain Center (Able to provide; equipment available): (check all that apply) Spinal Cord Stimulation      
Drug Delivery Systems      
Terminal Cancer Pain Management      
Chronic Pain Management      
Back 
Head and Neck      
Neuropathies      
Other    Specify  
 
Attach a brief description from the Pain Center Director on why this Pain Center should be designated as Pain Center of Excellence in Pain Practice. (Comment up to 500 words in the space provided. You may send additional comments and supplemental documentation in support of your application via email to: wip@worldinstituteofpain.org.)
 
Professional References: (Provide complete name, address and e-mail address of two physician references, one of which should be an FIPP.)  Reference 1 Name:     FIPP?  Yes     No 
 Reference 1 Address:  
 Reference 1 Email:  

 Reference 2 Name:     FIPP?  Yes     No 
 Reference 2 Address:  
 Reference 2 Email:  
 
 


 
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