Thank you for choosing the medical offices of TF Medical Group, LLC to request refill medication with one of our doctors, please fill in the information below.

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

calendar

STABLE CLIENT MONITORING REVIEW

HELLO, YOU ACKNOWLEDGE BY SIGNING BELOW (YOUR'S-THE CLIENT- OR YOUR LEGAL GUARDIAN OR REPRESENTATIVE'S) THAT YOU HAVE COME TO THE CLINICAL OFFICE MAINTAINED BY TOP FLIGHT MEDICAL GROUP FREELY SEEKING CONSULTATION, MANAGEMENT, CONTINUED CARE AND OR TREATMENT SERVICES ON THIS DATE
 *
clear

Your Information

Date Of Appointment

Appointment Information

Appointment/visit reason

"It has long been recognized that successful medical care requires an ongoing collaborative effort between patients and physicians. Physician and patient are bound in a potential partnership that requires both individuals to take an active role in the healing process"

If you are being prescribed medications by our group for pain control, do you believe that you need to be taking the medication AND that it helps you function in your everyday life *

Are you taking medications as prescribed *

IF THERE HAVE NOT BEEN ANY CHANGES SINCE YOUR LAST VIST SKIP THIS SECTION PLEASE

The next several questions are for things/situations that are new since your last visit with us

System Review

Any new problems with any of the following *
Since your last visit with us check any of the following that apply *
Verify by signing  below that the form has been completed by the client, legal guardian, or other authorized representative, with the information provided coming from the client
 *
clear
calendar

KEEPING IN TOUCH IS ESSENTIAL !!

WE LIKE "TECH" PLEASE CHECK ANY MEANS OF ACCESS THAT YOU HAVE REGULARLY OR USE REGULARLY

Remember, we recommend that you never discuss your medication or treatment with other persons in the facility except the providers . Also, keep your belongings, including your medications, documents, etc with you or your trusted guardian or representative at all times. We will never take your medications from your (or their(s)) view. If one of of team/ staff, asks for you to give them your medication(s) before you enter the exam room or counting /monitoring area - DO NOT. Please make provider aware if this happens.

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

WOMEN IF THERE IS ANY CHANCE THAT YOU ARE CURRENTLY PREGNANT TELL US NOW PLEASE

 *

THERE IS NOTHING MORE TO DO PLEASE PRESS THE SUBMIT BUTTON AND WAIT FOR THE "GREEN" CHECK MARK TO CONFIRM THAT YOUR FORM HAS BEEN PROPERLY SUBMITTED... THANKS FOR FINISHING!!!

property of top flight medical group, llc all rights reserved do not duplicate any part

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