Oklahoma Pain Treatment Centers

🛡️

HIPAA Notice: Photos are analyzed in memory only and never stored on any server. All data is transmitted over encrypted HTTPS.

Scan Patient Document

Photo a face sheet or any patient document. AI will auto-fill the referral form instantly.

📋

📷

Face sheet · Patient chart · Any patient document

Analyzing document… Extracting patient data with AI

✅ AI extracted fields:

— or skip and fill manually —

Teal fields were AI-filled — please verify.

👤

Last Name*

First Name*

Date of Birth*

Sex

Patient Phone*

🩺

Jacob Caylor MD

Blake Christensen DO

* Patient will be scheduled with the next available provider if no preference is selected.

🏥

Provider Name*

Practice / Clinic

📝

Urgency

Chief Complaint & Reason for Referral*

Additional Notes

Verify all information before sending.

🔍

The referral will be emailed as a formatted PDF to our office.

✉️

📬 Fully Automated Clicking "Send Referral" will generate the PDF and send it directly to the OPTC office automatically.

✓

The referral PDF has been prepared and your email app opened. Please attach the downloaded PDF and send to complete the referral.

REF-000000

Oklahoma Pain Treatment Centers will contact the patient to schedule their appointment based on the selected urgency.