THANK YOU FOR  KEEPING  YOUR SCHEDULED APPOINTMENT FOR   STUDY TODAY. PLEASE  COMPLETE THE FOLLOWING  SHORT  FORM. WE WILL BE  WITH YOU SHORTLY. ALL ASTERISKED ITEMS  REQUIRE SOME RESPONSE

IF THIS FORM IS NOT BEING COMPLETED 5-7 DAYS PRIOR TO YOUR SCHEDULED VISIT PLEASE STOP HERE AND CONTACT OUR OFFICE BEFORE YOU COMPLETE THE FORM. YOU MUST OBTAIN AN EXCEPTION CODE IN ORDER FOR THE FORM TO BE ACCEPTED BY THE GROUP

Patient Information

THIS FORM SHOULD BE COMPLETED 5 DAYS PRIOR TO YOUR APPOINTMENT. IF FOR ANY REASON THE FORM IS BEING COMPLETED LESS THAN 3 DAYS PRIOR TO YOUR APPOINTMENT, THE FORM MAY NOT BE ACCEPTED. SO PLEASE CALL, EMAIL OR MESSAGE US FIRST FOR APPROPRIATE INSTRUCTIONS

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Save & Return

Save your progress and complete this form later. (optional)

Date and Time

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REMEMBER TO BRING ALL PAIN MEDICATIONS USED WITHIN THE LAST 30 DAYS (INCLUDING PILLS, PATCHES, BOTTLES, BOXES) PILLS SHOULD BE IN THE BOTTLES THAT THEY CAME IN OR IN YOUR DAILY MEDICATION PLANNER AND UNUSED PATCHES SHOULD BE IN THE APPROPRIATE BOX OR IN PLANNER AND BRING JOURNAL UNLESS SENT ELECTRONICALLY

Appointment Information

DO YOU HAVE ANY NEW MEDICATIONS  SINCE LAST  VISIT *
DO YOU HAVE ANY NEW MEDICATION OR DRUG ALLERGIES *
IF  YOU ARE  TAKING  PRESCRIBED MEDICATION  ARE YOU  TAKING IT CORRECTLY *
HAVE YOU USED ANY ILLEGAL DRUG SINCE THE  LAST  TIME  WE SAW  YOU HERE *

Evaluation Information and Consent Page- Complete this if you are having a study

The patient or person legally responsible for the patient: The right to be informed about your condition and the recommended medical, surgical or diagnostic study options to be performed so that you can make an informed decision as to whether or not to undergo the procedure after knowing the risks, benefits, and alternatives. This disclose  is an effort to inform you so that you may give or withhold consent to the study at any time prior to its performance.
 
 I voluntarily request Dr.  Molette, as my physician and such associates, student, technical assistance and other health care providers as Dr. Molette may deem necessary, to evaluate and treat my condition, which has been explained to me as: Severe numnbess, tingling, burning,  or weakness  and pain in (location):
I understand the following surgical and/or diagnostic study (studies) is planned for me. I understand the nature and purpose of the study (studies) and I voluntarily consented to (choose study type):
 
 
I understand that Dr.  Molette may discover other or different conditions which require additional and or different aspects to the study than those  already planned; I authorize Dr.  Molette and such associates, students, technical assistants and other health care providers to perform such additional aspects of the study which are advisable in his professional judgment.  I
 
 
 
 
 *
consent to any additional aspects of the study as deemed necessary
 
 
 
No guarantee: I understand that no warranty or guarantee has been made to me as to the result of the medical evaluation for services rendered to me or a cure of my medical condition.
 
Benefits: To have evaluation of my medical condition.
 
 Risks: Just  as there may be risks and hazards and continuing the present condition without evaluation, there are also risks and hazards related to the performance of medical studies, medical and/or diagnostic studies planned for me. I understand that common to surgical, medical and/or diagnostic studies, there is the potential for electrical interference of any electronic device that I may have implanted, infection, increase in  any of my usual pain  usually temporary and brief, blood clots in the veins, bleeding, allergic reactions and even death. These additional risks may require bedrest, or bandages, bloodpatch(s), etc. 
 
 Alternatives: Alternative is not to have the study (studies) done.
 
Photographs: Observers: I consent to the photographing and videotaping or one or the other or both to be performed into the presence of students or other observers present in the study room to observe for the purpose of advancing medical education. I am aware that Dr. Molette has permission or my consent. Any videotaping/photography or other similar documentation, if used, would include appropriate portions of my body for medical, scientific, poor educational purposes. My identity  would not be revealed by descriptive text accompanying the pictures.
 
 I have been given an opportunity to ask questions about my conditions, alternative forms of evaluation, risks, and benefits of the planned evaluation (s) and the risk/consequences of study. All  questions have been answered to my satisfaction and I amaware that if I have more questions, I may/should ask them at the time of the study (studies). I have sufficient information to give this informed consent. I certify that this form has been fully explained to me. I have read this form or it has been read to me. The blank spaces have been filled in by me or my advocate (legal) and I understand its contents.
THANK YOU FOR COMPLETING  THIS FORM WE WILL BE  CONTACTING  YOU AFTER THE PROCEDURE TODAY!!

PLEASE BRING ALL NEWLY PRESCRIBED MEDICATION(S) SINCE YOUR LAST VISIT WITH US

 
 
Please sign to confirm completion
 *
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REMEMBER TO BRING ALL PAIN MEDICATIONS USED WITHIN THE LAST 30 DAYS (INCLUDING PILLS, PATCHES, BOTTLES, BOXES) PILLS SHOULD BE IN THE BOTTLES THAT THEY CAME IN OR IN YOUR DAILY MEDICATION PLANNER AND UNUSED PATCHES SHOULD BE IN THE APPROPRIATE BOX OR IN PLANNER AND BRING JOURNAL UNLESS SENT ELECTRONICALLY

PLEASE CHECK WEBSITE (tfmgglobal.com) FOR IMPORTANT UPDATES

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please contact us via our website: tfmgglobal.com email: tfmg@flightmedicalgroup.com
or phone: 615.340.3436/emergencies 615.680.9055