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TF MEDICAL STUDY

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

WHICH CITY IS THE CLINIC LOCATED IN THAT YOU ARE COMING TO FOR THIS VISIT *

WHAT IS YOUR APPOINTMENT DATE (CLICK THE CALENDAR PLEASE TO CHOOSE) * +

First initial *

Middle Initial

Last Name *

Birth Date (MM/DD/YYYY)

Daytime Phone *

enter email address

re-enter email address

Save & Return

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

Date and Time

WHAT TYPE OF STUDY ARE YOU HAVING DONE TODAY *

IF YOU HAVE ANY QUESTIONS ABOUT THE STUDY TODAY WHAT IS (ARE) IT (THEY)

Date of study +

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 *

YES

IF you are taking new prescription medication since your last visit with us what is the name of it and who prescribed it. If none, type in NA or NONE *

DO YOU HAVE ANY NEW MEDICATION OR DRUG ALLERGIES *

YES

IF YOU ARE TAKING PRESCRIBED MEDICATION ARE YOU TAKING IT CORRECTLY *

YES

If you are taking any blood thinning agent (example: Plavix), please list it here otherwise typa NA or None *

Please list all medical conditions (IF NONE THEN TYPE NA OR NONE) *

HAVE YOU USED ANY ILLEGAL DRUG SINCE THE LAST TIME WE SAW YOU HERE *

YES

IF YOU HAVE USED AN ILLEGAL DRUG SINCE YOUR LAST VISIT TELL US WHAT IT WAS AND WHY

Do you have any (active or non-active) implanted electrical device- if so what is it and where is it located. If not type NA or None *

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):

If the problem is not listed then list the other condition here

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

DO NOT

consent to any additional aspects of the study as deemed necessary

if you do NOT consent to some aspect of the study/test please indicate why (otherwise type in NA) *

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

clear

YOUR FIRST AND LAST NAME *