Patient Forms



Welcome to Valley Medical & Wellness! All patient forms can be completed online or printed and filled out by hand.

New Patients

Before scheduling an initial consultation, please complete our New Patient Packet. For Chronic Pain Management consultations, please complete the Release of Information Form for any medical clinics you have attended within the last 12 months regarding your pain concern and collect any imaging results, such as MRI, XRay, or CT films. This will help expedite your appointment and maximize your time with our providers. You may also complete these forms electronically via our secure messaging app in the lower right corner of the website.

Select the button below to complete the form online:


Complete Release of Information


Complete New Patient Packet



Referrals for Pain Management require at least the most recent visit note (last 3 and imaging preferred).
Please use Patient Referral Form below.

Referrals can be emailed to or faxed to 612-444-9000.
Our mailing address is 2428 E. 117th St., Burnsville, MN 55337.

open new patient packet  >
open release of information form  >
open patient referral form  >

Questions or concerns, please call (612) 444-3000 or email us at
You may also securely text us at (612)-453-1965.

Our Locations

Choose your preferred location

Fax Number: 612-444-9000