Center for Amplified Musculoskeletal Pain Syndrome Patient Intake

Our Center wants to ensure that your child gets the best and most appropriate medical care possible. In order to determine the appropriateness of evaluation in our Center, we require that the following information be sent to us within two weeks. If a primary care provider or physician specialist at Children’s Hospital of Philadelphia referred you, you do not need to provide us these three pieces of information. You only need to complete the form.

  • A medical summary or clinical summary letter is required from the referring primary care provider or physician specialist as well as medical records from these visits.
  • Copies of previously completed medical tests, radiology reports and laboratory reports from the referring physician or other specialists only as they relate to your child’s amplified pain problem.
  • A copy of the front and back of your current insurance card. We will not review paperwork without this information.

Please email or fax this information to the AMPS Clinic Coordinator: 

All new patients to our Center must complete the following form.

Contact Information
Patient Information
Has your child’s pain affected their ability to do any of the following?