Stellate Ganglion Block Screening

Why do I need to fill out this form?

We respect your time and want to do what we can to help relieve your pain as quickly as possible. In order to schedule you as soon as possible, we need the following information. Please note that we do not need to know the details of your traumatic experience to treat you. You do not need to share the details of your traumatic experience with our staff in order to be scheduled. 

Instructions

Please follow this link to find a PCL-5 screening test form. Print and complete this form.

Once you have completed this form, email it and your answers to the questions below to our office at annapolis@rosm.org. Currently, only our Annapolis location can provide SGB.

Be sure to include your name and means of contact, such as a phone number. Our receptionist will use this phone number to contact you about scheduling your appointment.

You should also be prepared to answer the following questions. Please note that these are all yes or no questions. You do not need to share any additional details.

A Note About Insurance

Most insurances do not cover SGB as a treatment for PTSD. This means that you will most likely have to pay for your procedure out-of-pocket. 

Screening Questions

Are you active duty military? Active duty personnel can recieve SGB at the Pain Clinic at Walter Reed in Bethesda, MD from Dr. Aubrey Verdun (phone: 301-319-8600). 

Are you a former service member or emergency first responder (EMS)?

Have you had a traumatic experience?

Do you have a mental health diagnosis? If so, are you currently under the care of a behavioral health professional or physician?

Do you take any medications that thin your blood, such as coumadin, heparin, or aspirin?