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TF MEDICAL PROCEDURE

THANK YOU FOR KEEPING YOUR SCHEDULED APPOINTMENT FOR PROCEDURE TODAY. PLEASE COMPLETE THE FOLLOWING SHORT FORM. WE WILL BE WITH YOU SHORTLY

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

Patient Information

First Initial *

Middle Initial

Last Name *

Birth Date (MM/DD/YYYY) *

email address

Please be sure that when you come in you update all contact information with one of our team members

Date and Time

What is the date of your planned procedure *

WHERE (WHICH CITY IS THE LOCATION) IS YOUR PROCEDURE GOING TO BE PERFORMED *

WHAT TYPE OF PROCEDURE/STUDY ARE YOU HAVING DONE TODAY *

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

Today's Date

Appointment Information

DO YOU HAVE ANY NEW MEDICATIONS SINCE LAST VISIT *

YES

NO

If you DO have new medications since your last visit with us, please list below, otherwise skip the box

DO YOU HAVE ANY NEW MEDICATION OR DRUG ALLERGIES *

YES

NO

If you DO have medication allergies please list. If not , then skip this box

If you are taking a blood thinning agent (example: coumadin/plavix), when is the last time that you took it. If you are NOT taking a blood thinning agent simply type NA or NONE *

IF YOU ARE TAKING PRESCRIBED MEDICATION ARE YOU TAKING IT CORRECTLY

YES

NO

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

YES

NO

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

Procedure Information and Consent Page- Complete this if you are having an injection procedure

The patient or person legally responsible for the patient: The right to be informed about your condition and the recommended medical, surgical or diagnostic procedure 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 procedure 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 treat my condition, which has been explained to me as: Severe pain in (location):

*

I understand the following surgical and/or diagnostic procedure is planned for me. I understand the nature and purpose of the procedure (s) and I voluntarily consented to (choose procedure type):

*

I understand that Dr. Molette may discover other or different conditions which require additional and or different procedures than those planned, including administration of blood or a blood derivative. I authorize Dr. Molette and such associates, students, technical assistants and other health care providers to perform such procedures including administration of blood or blood derivatives, which are advisable and his professional judgment.

Use of blood products: The need for, risk of, and alternative use of blood and blood products have been explained to me. I

*

DO NOT

Do

consent to the use of blood and blood products as deemed necessary

No guarantee: I understand that no warranty or guarantee has been made to me as to the result of the medical treatment for services rendered to me or a cure of my medical condition.

Benefits: To have a decrease in pain.

Risks: Just as there may be risks and hazards and continuing the present condition without treatment, there are also risks and hazards related to the performance of surgical, medical and/or diagnostic procedures planned for me. I understand that common to surgical, medical and/or diagnostic procedures, there is the potential for infection, blood clots in the veins or/and lungs, hemorrhage, allergic reactions and even death. Additionally, risks may include nerve damage, paralysis and spinal headaches. These additional risks may require bedrest and/or a blood patch (s) in order to get relief.

Alternatives: Alternative is not to have the procedure 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 operating/procedure 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 treatment, risks, and benefits of the planned procedure(s) and the risk/consequences of nontreatment. All questions have been answered to my satisfaction. 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 sign to confirm completion

*