TREATMENT CONSULTATION FORM
|
|
|
- Kenneth Cox
- 9 years ago
- Views:
Transcription
1 TREATMENT CONSULTATION FORM Consultation led by: Gender: M / F Weight Has your patient had other aesthetic procedures for the body? How did your patient hear about the CoolSculpting procedure? TREATMENT PLAN CoolCurve+ Applicator: (ez App 6.2) CoolCore Applicator: (ez App 6.3) CoolFit Applicator: CoolMax Applicator: (ez App 8.0) CoolSmooth Applicator: Total: PRICING Treatment price: Discount: Total: Savings: Notes: Patient Signature: In the U.S. and Taiwan, non-invasive fat reduction is cleared for the flank, abdomen and thigh. In Taiwan, non-invasive fat reduction is cleared only for the flank (love handle) and abdomen. The CoolSculpting Procedure for non-invasive fat reduction is available worldwide. CoolSculpting, the CoolSculpting logo, and the Snowflake design are registered trademarks and CoolCurve+, CoolCore, CoolFit, CoolMax, and CoolSmooth are trademarks of ZELTIQ Aesthetics, Inc All rights reserved. IC1373-B
2 TREATMENT CONSENT FORM The CoolSculpting procedure may use a non-invasive vacuum applicator to draw in tissue or a non-invasive surface applicator to deliver controlled cooling at the surface of the skin. The procedure is for spot reduction of fat. It is not a weight-loss solution and it does not replace traditional methods such as liposuction. Someone who is overweight can expect to see less visible improvement than someone who has smaller fat deposits. Clinical studies have shown that the CoolSculpting procedure will naturally remove fat cells but, as with most procedures, visible results will vary from person to person. Initial: What you can expect:» The suction pressure of a vacuum applicator may cause sensations of deep pulling, tugging and pinching. A surface applicator may cause sensations of pressure. You may experience intense stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside as the area becomes numb. Initial:» The treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur. You may feel a sense of nausea or dizziness as your body naturally warms and sensation returns to your treatment area. These are all normal reactions that typically resolve within minutes. Initial:» Bruising, swelling, and tenderness can occur in the treated area and it may appear red for a few hours after the applicator is removed. Initial:» You may feel a dulling of sensation in the treated area that can last for several weeks after your procedure. Other changes including deep itching, tingling, numbness, tenderness to the touch, pain in the treated area, strong cramping, muscle spasms, aching and/or soreness also have been reported after a CoolSculpting procedure. Initial:» Patient experiences will differ. Some patients may experience a delayed onset of the previously mentioned occurrences. Contact us immediately if any unusual side effects occur or if symptoms worsen over time. Initial:» You may start to see changes as early as three weeks after your CoolSculpting procedure, and you will experience the most dramatic results after one to three months. Your body will continue naturally to process the injured fat cells from your body for approximately four months after your procedure. Initial:» You may decide that additional treatments are needed to reach your desired outcome. Initial:» In rare cases, patients have experienced vasovagal symptoms during the treatment, and reported freeze burn, darker skin color, hardness, discrete nodules or enlargement of the treatment area. Surgical intervention may be required to correct the enlargement. Treatment may cause new hernia formation or exacerbate pre-existing hernia, which may require surgical repair. I understand that these and other unknown side effects may also occur. Initial: continued on next page
3 Do you have any of the following? :» Cryoglobulinemia or paroxysmal cold hemoglobinuria Yes / No» Known sensitivity to cold such as cold urticaria or Raynaud s disease Yes / No» Impaired peripheral circulation in the area to be treated Yes / No» Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy Yes / No» Impaired skin sensation Yes / No» Open or infected wounds Yes / No» Bleeding disorders or concomitant use of blood thinners Yes / No» Recent surgery or scar tissue in the area to be treated Yes / No» A hernia or history of hernia in the area to be treated or adjacent to treatment site Yes / No» Skin conditions such as eczema, dermatitis, or rashes Yes / No» Pregnancy or lactation Yes / No» Any active implanted devices such as pacemakers and defibrillators Yes / No Pictures will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed. Initial: As with most medical procedures, there are risks and side effects. These have been explained to me in detail. have read the above information, and I give my consent to be treated with the CoolSculpting procedure by [insert physician name] and [his/her] designated staff. I Dr. Print Name: Signature: Witness: The CoolSculpting procedure for non-invasive fat reduction is FDA-cleared for the flank (love handle), abdomen, and thigh. The CoolSculpting procedure for non-invasive fat reduction is available worldwide. ZELTIQ, CoolSculpting, the CoolSculpting logo and the Snowflake design are registered trademarks of ZELTIQ Aesthetics, Inc All rights reserved. The products described in this document may be covered by U.S. Patent 7,367,341. Other patents and patent applications pending worldwide. IC0326-G
4 PATIENT PHOTOGRAPHY RELEASE FORM I,, authorize [insert practice name], [insert physician name] and staff representatives, to take photographs of my body for medical purposes to be used for my patient care, marketing, literature and/or case presentations. I understand that:» Photographs are taken to capture treatment outcomes for the CoolSculpting procedure.» They may be used for print, visual or electronic media including but not limited to, scientific presentations, websites and for purposes of informing the medical profession or general public about the procedure. These uses may also include marketing on behalf of [insert practice name].» The images taken of me may be published by [insert practice name] and its agents.» I will not be identified by name in any of the published materials.» My face will not be shown in the photographs nor will they reveal my identity.» I have the right to revoke this authorization in writing at any time through a written revocation to [insert practice name]. I hereby release [insert practice name], [insert physician name] and its agents from any and all claims and demands arising out of, or in conjunction with, the use of the photographs. I certify that I have read this release carefully and fully understand its terms. If I have any questions I can contact [insert practice name] at [insert practice number]. If under 18, guardian or parent must sign. Print Name: Signature: Witness: Disclaimer: In the U.S., non-invasive fat reduction is cleared only for the flank, abdomen and thigh. In U.S Taiwan, non-invasive fat reduction is cleared only for the flank and abdomen. CoolSculpting, the CoolSculpting logo and the Snowflake design are registered trademarks of ZELTIQ Aesthetics, Inc All rights reserved. IC0325-C
5 FOR PRACTICE USE ONLY - NOT FOR DISTRIBUTION TREATMENT PLANNING FORM Patient ID/No: In the U.S., the CoolSculpting procedure for non-invasive fat reduction is cleared for the flank (love handle), abdomen, and thigh. The CoolSculpting procedure for non-invasive fat reduction is available worldwide. ZELTIQ, CoolSculpting, the CoolSculpting logo,and the Snowflake design are registered trademarks of ZELTIQ Aesthetics, Inc All rights reserved. The products described in this document may be covered by U.S. Patent 7,367,341. Other patents and patent applications pending worldwide. IC1372-C Available for download on CoolNet CoolNet.CoolSculpting.com
6 FOR PRACTICE USE ONLY - NOT FOR DISTRIBUTION TREATMENT PLANNING FORM Patient ID/No: In the U.S., the CoolSculpting procedure for non-invasive fat reduction is cleared for the flank (love handle), abdomen, and thigh. The CoolSculpting procedure for non-invasive fat reduction is available worldwide. ZELTIQ, CoolSculpting, the CoolSculpting logo,and the Snowflake design are registered trademarks of ZELTIQ Aesthetics, Inc All rights reserved. The products described in this document may be covered by U.S. Patent 7,367,341. Other patents and patent applications pending worldwide. IC1372-C Available for download on CoolNet CoolNet.CoolSculpting.com
7 PATIENT TAKE-HOME GUIDELINES What to expect after the CoolSculpting procedure:» Typically, there is minimal discomfort and recovery time after the CoolSculpting procedure. Most patients are able to return to their daily routine immediately after the procedure» The treated area may be red for up to a few hours after the applicator is removed.» Many patients have minimal discomfort following the procedure, however you may experience one or more of the following sensations: deep itching, tingling, numbness, tenderness to the touch, pain in the treated area, strong cramping, nausea, bloating, diarrhea, muscle spasms, aching and/or soreness. Consult your doctor if these conditions persist beyond two weeks or worsen over time.» Following the procedure, a gradual reduction in the thickness of the fat layer will take place. You may start to see changes as early as three weeks after the CoolSculpting procedure and you will experience the most dramatic results after one to three months. Your body will continue naturally to process the injured fat cells from your body for approximately four months after your procedure.» In rare cases, patients have reported darker skin color, hardness, discrete nodules, freeze burn, enlargement of the treated area, hernia or worsening of existing hernia following the CoolSculpting procedure. Surgical intervention may be required to correct the enlargement or hernia. Next steps:» Weight gain will prevent you from appreciating your full results. Maintaining a healthy diet and exercise routine after your procedure can help prevent this.» Schedule a follow-up medical assessment to review your clinical results and discuss the option of additional treatments to achieve desired fat reduction. Please call us at if your symptoms appear to worsen or last longer than two weeks. The CoolSculpting procedure for non-invasive fat reduction is FDA-cleared for the flank (love handle), abdomen, and thigh. The CoolSculpting procedure for non-invasive fat reduction is available worldwide. ZELTIQ, CoolSculpting, the CoolSculpting logo and the Snowflake design are registered trademarks of ZELTIQ Aesthetics, Inc All rights reserved. The products described in this document may be covered by U.S. Patent 7,367,341. Other patents and patent applications pending worldwide. IC0327-F
TRANSFORM YOUR BODY WITHOUT SURGERY OR DOWNTIME. Freeze your fat away with CryoSculpting
TRANSFORM YOUR BODY WITHOUT SURGERY OR DOWNTIME. Freeze your fat away with CryoSculpting BEFORE 12 WEEKS AFTER IT ALL BEGAN WITH NOT-SO-CHUBBY CHEEKS. 1 The revolutionary technology behind CoolSculpting
PREPARING YOUR PRACTICE FOR COOLSCULPTING
PREPARING YOUR PRACTICE FOR COOLSCULPTING Prepare Your Practice... Education Through Advanced CoolSculpting Certification» Identify your CoolSculpting Team Leader (CTL) 2 Patient Messaging... 4» Watch
Practice Marketing tools
Practice Marketing tools coolsculpting Practice Marketing tools Internal Marketing tools: Patient Brochures (male & female) Brochure Holder Countertop Displays (2) Exam Room Posters 18 x 24 (2) Photo Book
FEAR NO MIRROR EVERY VIEW OF YOU? ARE YOU READY TO LOVE. Eliminate stubborn fat without surgery or downtime and feel great from every angle.
FEAR NO MIRROR ARE YOU READY TO LOVE EVERY VIEW OF YOU? The sooner you set up your consultation, the sooner you ll see results in the mirror long-term results in those areas that have resisted all efforts
Futuristic Beauty. Buyers Guide
TM Futuristic Beauty Buyers Guide LoveLite is a fresh and innovative company who specialise in introducing new and exciting cosmetic beauty equipment, treatments and products into the UK. who are we? LoveLite
Surgical removal of fibroids through an abdominal incision-either up and down or bikini cut. The uterus and cervix are left in place.
What is an abdominal myomectomy? Surgical removal of fibroids through an abdominal incision-either up and down or bikini cut. The uterus and cervix are left in place. When is this surgery used? Treatment
Electrodiagnostic Testing
Electrodiagnostic Testing Electromyogram and Nerve Conduction Study North American Spine Society Public Education Series What Is Electrodiagnostic Testing? The term electrodiagnostic testing covers a
Non-Surgical Fat Reduction using the CoolSmooth Conformable Surface Cryolipolysis Applicator. W. Grant Stevens, MD, FACS
Non-Surgical Fat Reduction using the CoolSmooth Conformable Surface Cryolipolysis Applicator W. Grant Stevens, MD, FACS As published in Plastic Surgery Pulse News, Volume 6, Number 2, 2014. http://www.plasticsurgerypulsenews.com/18/article_dtl.php?qncategoryid=174&qnarticleid=351&qncurpage=1
Aesthetic Facial Plastic Surgery, PLLC 1810 116th Ave NE #102 Bellevue, WA 98004
Aesthetic Facial Plastic Surgery, PLLC 1810 116th Ave NE #102 Bellevue, WA 98004 GENERAL, HIPAA, PHOTO VIDEO INFORMED CONSENT FORM, AND RELEASE AGREEMENT Aesthetic Facial Plastic Surgery, PLLC s ("AFPS"),
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
Structual Fat Transfer (Fat Injection to the Breast) Musgrove Park Hospital is part of Taunton and Somerset NHS Foundation Trust. Patient Information
Structual Fat Transfer (Fat Injection to the Breast) Musgrove Park Hospital is part of Taunton and Somerset NHS Foundation Trust Patient Information Introduction This information is for patients undergoing
Laparoscopic Gallbladder Removal (Cholecystectomy) Patient Information from SAGES
Laparoscopic Gallbladder Removal (Cholecystectomy) Patient Information from SAGES Gallbladder removal is one of the most commonly performed surgical procedures. Gallbladder removal surgery is usually performed
Total Abdominal Hysterectomy
What is a total abdominal hysterectomy? Is the removal of the uterus and cervix through an abdominal incision (either an up and down or bikini cut). Removal of the ovaries and tubes depends on the patient.
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
Chapter 4 Physiological Therapeutics. 1 Cryotherapy
Chapter 4 Physiological Therapeutics 1 Cryotherapy CRYOTHERAPY PHYSIOLOGIC EFFECTS OF ICE APPLICATION 1. Decreased circulation 5. Increased tissue stiffness 2. Local vasoconstriction 6. Decreased muscle
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
Total Vaginal Hysterectomy
What is a total vaginal hysterectomy? Is the removal of the uterus and cervix through the vagina. Removal of the ovaries and tubes depends on the patient. Why is this surgery used? To treat disease of
LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527 Patient Information Name First Middle Last Address City State Zip Phone Other Contact Email Social Security # DOB
Electronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
X-Plain Varicose Veins Reference Summary
X-Plain Varicose Veins Reference Summary Introduction Varicose veins are very common, in both women and men. Varicose veins can be painful and unattractive. Vein doctors use non-invasive ultrasound imaging
Laparoscopic Bilateral Salpingo-Oophorectomy
Laparoscopic Bilateral Salpingo-Oophorectomy What is a? This is a surgery where your doctor uses a thin, lighted camera and small surgical tool placed through a small (1/2 inch) incision usually in the
RALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
Blepharoplasty - Eyelid Surgery
Blepharoplasty - Eyelid Surgery Introduction Eyelid surgery repairs sagging or drooping eyelids. The surgery is also known as blepharoplasty, or an eyelid lift. Sagging or drooping eyelids happen naturally
Laparoscopic Cholecystectomy
Laparoscopic Cholecystectomy Gallbladder removal is one of the most commonly performed surgical procedures in the United States. Today,gallbladder surgery is performed laparoscopically. The medical name
17. Undiagnosed lumps and bumps and unexplained areas of pain. 2. Varicose veins (do not treat anything below the vein site).
15. Acute rheumatism. 16. Asthma. 17. Undiagnosed lumps and bumps and unexplained areas of pain. 18. Whiplash. 19. Slipped Disc. LOCAL CONTRA-INDICATIONS 1. Skin diseases (non contagious). 2. Varicose
Excision of Vaginal Mesh
What is excision of vaginal mesh? This procedure is done to remove mesh from the vagina. When is this surgery used? If mesh has eroded into the vagina, bladder, urethra, or bowel If there is pain associated
treatment of varicose and spider veins patient information SAMPLE a publication by advancing vein care
treatment of varicose and spider veins patient information a publication by advancing vein care Since most veins lie deep to the skin s surface, vein disorders are not always visible to the naked eye.
Please read these instructions carefully before using Poise* Bladder Supports
For the Temporary Management of Stress Urinary Incontinence in Women INSTRUCTIONS FOR USE Please read these instructions carefully before using Poise* Bladder Supports 500000023088 For the Temporary Management
Inguinal Hernia (Female)
Inguinal Hernia (Female) WHAT IS AN INGUINAL HERNIA? 2 WHAT CAUSES AN INGUINAL HERNIA? 2 WHAT DOES TREATMENT / MANAGEMENT INVOLVE? 3 DAY SURGERY MANAGEMENT 3 SURGICAL REPAIR 4 WHAT ARE THE RISKS/COMPLICATIONS
PATIENT CONSENT TO PROCEDURE - ROUX-EN-Y GASTRIC BYPASS
As a patient you must be adequately informed about your condition and the recommended surgical procedure. Please read this document carefully and ask about anything you do not understand. Please initial
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
CHAPTER 15 SCLEROTHERAPY FOR VENOUS DISEASE
Introduction CHAPTER 15 SCLEROTHERAPY FOR VENOUS DISEASE Original authors: Niren Angle, John J. Bergan, Joshua I. Greenberg, and J. Leonel Villavicencio Abstracted by Teresa L. Carman New technology has
INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM
INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM NAME: DATE: 1. PURPOSE AND EXPLANATION OF PROCEDURE I hereby consent to voluntarily engage in an acceptable
INFORMED CONSENT FOR SLEEVE GASTRECTOMY
INFORMED CONSENT FOR SLEEVE GASTRECTOMY This informed-consent document has been prepared to help inform you about your Sleeve Gastrectomy including the risks and benefits, as well as alternative treatments.
Recto-vaginal Fistula Repair
What is a recto-vaginal fistula repair? Rectovaginal fistula repair is a procedure in which the healthy tissue between the rectum and vagina is closed in multiple tissue layers. An incision is made either
Tired, Aching Legs? Swollen Ankles? Varicose Veins?
Tired, Aching Legs? Swollen Ankles? Varicose Veins? Healthy Legs 2006 http://healthylegs.com Page 1 Venous disorders are widespread Leg problems are widespread throughout the world, but what most people
MOHS MICROGRAPHIC SURGERY
MOHS MICROGRAPHIC SURGERY UMass Memorial Medical Center 55 Lake Avenue North Worcester, MA 01655 (508) 856-1666 Dr. Mary Maloney This booklet is intended to explain Mohs surgery to you. It is not, however,
VARICOSE VEINS. Information Leaflet. Your Health. Our Priority. VTE Ambulatory Clinic Stepping Hill Hospital
VARICOSE VEINS Information Leaflet Your Health. Our Priority. Page 2 of 7 Varicose Veins There are no accurate figures for the number of people with varicose veins. Some studies suggest that 3 in 100 people
INFORMED CONSENT DERMABRASION
INFORMED CONSENT DERMABRASION INSTRUCTION This is an informed-consent document which has been prepared to help your plastic surgeon inform you about dermabrasion, its risks, and alternative treatments.
ARPwave NeuroTherapy / Physical Therapy 255 Park Avenue, Suite 1000, Worcester, Massachusetts 01609 508-202-9173 / www.bostonarpwave.
Patient Consent to Treat ( ) Physical Therapy ( ) ARPwave Therapy When a patient seeks physical therapy in this office, it is essential for both the staff and the patient to work towards the same objective.
Varicose veins - 1 -
Varicose veins - 1 - Varicose Veins About 3 in 10 adults develop varicose veins at some time in their life. Most people with varicose veins do not have an underlying disease and they usually occur for
Femoral Hernia Repair
Femoral Hernia Repair WHAT IS A FEMORAL HERNIA REPAIR? 2 WHAT CAUSES A FEMORAL HERNIA? 2 WHAT DOES TREATMENT/ MANAGEMENT INVOLVE? 3 DAY SURGERY MANAGEMENT 3 SURGICAL REPAIR 4 WHAT ARE THE RISKS/COMPLICATIONS
X-Plain Inguinal Hernia Repair Reference Summary
X-Plain Inguinal Hernia Repair Reference Summary Introduction Hernias are common conditions that affect men and women of all ages. Your doctor may recommend a hernia operation. The decision whether or
Chemotherapy Side Effects Worksheet
Page 1 of 6 Chemotherapy Side Effects Worksheet Medicines or drugs that destroy cancer cells are called cancer chemotherapy. It is sometimes the first choice for treating many cancers. Chemotherapy differs
VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions
18 HEALY DR. WINSTON SALEM, NC 710 PH. 6-768-50 FAX- 768-19 Scott W. Baker, MD Patient Instructions 1. Bring a list of all regular medications and dosages.. Bring your insurance card and all necessary
Patient Information and Consent for Medical/Laser/Intense Pulsed Light Treatment. VASClinic PROCEDURES
This consent form includes general descriptions of various dermatological treatments, including possible benefits and risks that may occur as a result of these treatments. Your doctor or nurse will describe
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
Informed Consent For Laser Hair Removal
Informed Consent For Laser Hair Removal INSTRUCTIONS This informed-consent document has been prepared to help inform you about laser procedures, its risks, as well as alternative treatment(s). It is important
Hysteroscopy. What is a hysteroscopy? When is this surgery used? How do I prepare for surgery?
What is a hysteroscopy? This is a procedure where a doctor uses a thin tube with a tiny camera to look inside the uterus. There are no incisions. Saline solution is used to expand the uterus in order to
For the Patient: Paclitaxel injection Other names: TAXOL
For the Patient: Paclitaxel injection Other names: TAXOL Paclitaxel (pak'' li tax' el) is a drug that is used to treat many types of cancer. It is a clear liquid that is injected into a vein. Tell your
Integra. MCP Joint Replacement PATIENT INFORMATION
Integra MCP Joint Replacement PATIENT INFORMATION Integra MCP Patient Information This brochure summarizes information about the use, risks, and benefits of the Integra MCP finger implant. Be sure to discuss
ABDOMINOPLASTY - FREQUENTLY ASKED QUESTIONS (FAQs)
Executive Level E1, Excen Centre, 119 Willoughby Road, Crows Nest 2065 Tel: 02 9817 7585 www.mycosmeticclinic.net AFFORDABILITY WITH EXCELLENCE Liposuction Breast Augmentation Abdominoplasty Eyelids Surgery
Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )
Patient Information Date: First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone:
Therapeutic Massage .(W). Chiropractor
Therapeutic Massage Please take a moment to answer the following questions. The information you provide will be used to customize your session to your needs and exclude any techniques that may be medically
Breast Reduction Post-Operative Instructions
Breast Reduction Post-Operative Instructions What are my post-operative instructions? Have someone drive you home after surgery and help you at home for 1-2 days. Get plenty of rest and follow a balanced
How To Treat Shima Lipolaser
Shima Lipolaser Client Information Name: Last name: Date: Date of Birth (mm/dd/yy): Sex: male female Mailing Address: City: Province: Postal Code: Phone #: (C) (H) (W) E-mail address (Please print): Purpose
TREATMENT OF VARICOSE AND SPIDER VEINS Patient Info
TREATMENT OF VARICOSE AND SPIDER VEINS Patient Info www.heartofthevillages.com TIRED & ACHING LEGS? If you suffer from varicose and spider veins, you are not alone. It is estimated that there are more
Spotlight Series: Interventional Radiology. Varicose Veins and Venous Insufficiency
Spotlight Series: Interventional Radiology Varicose Veins and Venous Insufficiency What is venous insufficiency? Spectrum of Disease Spider veins and telangiectasias Small reddish and purple veins near
CHPN Review Course Pain Management Part 1 Hospice and Palliative Nurses Association
CHPN Review Course Pain Management Part 1 Disclosures Bonnie Morgan has no real or perceived conflicts of interest that relate to this presentation. Copyright 2015 by the. HPNA has the exclusive rights
GASTRIC BYPASS SURGERY CONSENT FORM
Page 1 of 6 I, have been asked to read carefully all of the (name of patient or substitute decision-maker) information contained in this consent form and to consent to the procedure described below on
Total Vaginal Hysterectomy with an Anterior and Posterior Repair
Total Vaginal Hysterectomy with an Anterior and Posterior Repair What is a total vaginal hysterectomy with an anterior and posterior repair? Total vaginal hysterectomy is the removal of the uterus and
Laparoscopic Cholecystectomy
Laparoscopic Cholecystectomy Removal of Gall Bladder Page 12 Patient Information Further Information We endeavour to provide an excellent service at all times, but should you have any concerns please,
X-Plain Diabetes - Introduction Reference Summary
X-Plain Diabetes - Introduction Reference Summary Introduction Diabetes is a disease that affects millions of Americans every year. Your doctor may have informed you that you have diabetes. Although there
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -
Personal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer
Adult Forearm Fractures
Adult Forearm Fractures Your forearm is made up of two bones, the radius and ulna. In most cases of adult forearm fractures, both bones are broken. Fractures of the forearm can occur near the wrist at
A separate consent form for the use of breast implants in conjunction with mastopexy is necessary.
INFORMED CONSENT BREAST LIFT (MASTOPEXY) INSTRUCTIONS This is an informed consent document that has been prepared to help your plastic surgeon inform you about mastopexy surgery, its risks, and alternative
KNEE LIGAMENT REPAIR AND RECONSTRUCTION INFORMED CONSENT INFORMATION
KNEE LIGAMENT REPAIR AND RECONSTRUCTION INFORMED CONSENT INFORMATION The purpose of this document is to provide written information regarding the risks, benefits and alternatives of the procedure named
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
Varicose Veins and Spider Veins
page 1 Varicose Veins and Spider Veins Q: What are varicose veins and spider A: Varicose (VAR-i-kos) veins are enlarged veins that can be blue, red, or fleshcolored. They often look like cords and appear
Informed Consent for Cosmetic Laser Skin Resurfacing with the DOT laser
Informed Consent for Cosmetic Laser Skin Resurfacing with the DOT laser INSTRUCTIONS This informed-consent document has been prepared to help inform you about laser procedure, its risks, as well as alternative
Hernia- Open Inguinal Hernia Repair PROCEDURAL CONSENT FORM. A. Interpreter / cultural needs. B. Condition and treatment
DO NOT WRITE IN THIS BINDING MARGIN v5.00-04/2011 SW9317 Hernia- Open Inguinal Hernia Repair Facility: A. Interpreter / cultural needs An Interpreter Service is required? Yes No If Yes, is a qualified
INSULIN INJECTION KNOW-HOW
0-0- 0 INSULIN INJECTION KNOW-HOW pro tips (and tricks) for easier and better Insulin Injections ABDOMEN THIGHS BUTTOCKS ARMS recommended injection sites WHERE IS THE BEST PLACE TO GIVE INJECTIONS? 0-
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
Kensington Eye Center 4701 Randolph Road, #G-2 Rockville, MD 20852 (301) 881-5701 www.keceyes.com
Kensington Eye Center 4701 Randolph Road, #G-2 Rockville, MD 20852 (301) 881-5701 www.keceyes.com Natasha L. Herz, MD INFORMED CONSENT FOR DESCEMET S STRIPPING and AUTOMATED ENDOTHELIAL KERATOPLASTY (DSAEK)
PATIENT INFORMATION BOOKLET
(060110) VISIONCARE S IMPLANTABLE MINIATURE TELESCOPE ( BY DR. ISAAC LIPSHITZ ) AN INTRAOCULAR TELESCOPE FOR TREATING SEVERE TO PROFOUND VISION IMPAIRMENT DUE TO BILATERAL END-STAGE AGE-RELATED MACULAR
Lumbar Laminectomy and Interspinous Process Fusion
Lumbar Laminectomy and Interspinous Process Fusion Introduction Low back and leg pain caused by pinched nerves in the back is a common condition that limits your ability to move, walk, and work. This condition
St. Louis Eye Care Specialists, LLC Andrew N. Blatt, MD
St. Louis Eye Care Specialists, LLC Andrew N. Blatt, MD 675 Old Ballas Rd. Suite 220 St. Louis, MO 63141 Phone:314-997-EYES Fax: 314-997-3911 Toll Free: 866-869-3937 STRABISMUS SURGERY (Post-Op Strabismus
Michael A. Boss, M.D. FMH Plastic, Reconstructive und Aesthetic Surgery
Michael A. Boss, M.D. FMH Plastic, Reconstructive und Aesthetic Surgery Boss Aesthetic Center Schauplatzgasse 23 CH-3011 Bern Switzerland +41 31 311 7691 www.aesthetic-center.com B r e a s t A u g m e
Breast Implants: Local Complications and Adverse Outcomes
Breast Implants: Local Complications and Adverse Outcomes This booklet highlights the most common problems associated with silicone gel-filled and saline-filled breast implants: those that occur in the
Varicose Veins Operation. Patient information Leaflet
Varicose Veins Operation Patient information Leaflet 22 nd August 2014 WHAT IS VARICOSE VEIN SURGERY (HIGH LIGATION AND MULTIPLE AVULSIONS) The operation varies from case to case, depending on where the
SCRIPT NUMBER 122 VARICOSE VEINS - 2 (TWO SPEAKERS)
SCRIPT NUMBER 122 VARICOSE VEINS - 2 (TWO SPEAKERS) PROGRAM NAME: HEALTH NUGGETS PROGRAM TITLE: VARICOSE VEINS - 2 PROGRAM NUMBER: 122 SUBJECT: SYMPTOMS, CAUSES, TREATMENT, PREVENTION OF VARICOSE VEINS
THERAPEUTIC USE OF HEAT AND COLD
THERAPEUTIC USE OF HEAT AND COLD INTRODUCTION Heat and cold are simple and very effective therapeutic tools. They can be used locally or over the whole body, and the proper application of heat and cold
Other Noninfectious Diseases. Chapter 31 Lesson 3
Other Noninfectious Diseases Chapter 31 Lesson 3 Diabetes Diabetes- a chronic disease that affects the way body cells convert food into energy. Diabetes is the seventh leading cause of death by disease
Weight Loss before Hernia Repair Surgery
Weight Loss before Hernia Repair Surgery What is an abdominal wall hernia? The abdomen (commonly called the belly) holds many of your internal organs. In the front, the abdomen is protected by a tough
OPERATION:... Proximal tibial osteotomy Distal femoral osteotomy
AFFIX PATIENT DETAIL STICKER HERE Forename.. Surname NHS Organisation. Responsible surgeon. Job Title Hospital Number... D.O.B.././ No special requirements OPERATION:..... Proximal tibial osteotomy Distal
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
Basal Cell Carcinoma Affecting the Eye Your Treatment Explained
Basal Cell Carcinoma Affecting the Eye Your Treatment Explained Patient Information Introduction This booklet is designed to give you information about having a Basal Cell Carcinoma near your eye and the
LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS
PLEASE PRINT PATIENT LAST NAME: FIRST NAME DATE OF BIRTH: / / AGE: ADDRESS: APT CITY STATE ZIP HOME PHONE # CELL PHONE # WORK PHONE # SEX M F MARITAL STATUS DRIVER S LICENSE # SOCIAL SECURITY # - - EMPLOYER
Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP. Primary Care Provider:
Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP Primary Care Provider: If you are considering hepatitis C treatment, please read this treatment
Pain Management after Surgery Patient Information Booklet
Pain Management after Surgery Patient Information Booklet PATS 509-15-05 Your Health Care Be Involved Be involved in your healthcare. Speak up if you have questions or concerns about your care. Tell a
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM FEC-T. Patient s first names. Date of birth.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM FEC-T Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas
F REQUENTLY A SKED Q UESTIONS. and Spider Veins
page 1 Varicose Veins moves up the legs. If the one-way valves become weak, blood can leak back into the vein and collect there. This problem is called venous insufficiency. Pooled blood enlarges the vein
How To Get A Medical Insurance Plan From A Doctor
PATIENT DEMOGRAPHICS SHEET Patient Name: Parent/Legal Guardian Name: Date of Birth: Phone: Address: CITY STATE ZIP Social Security Number: Patient Phone: Sex: M F Home Cell Business Okay to leave detailed
Medicines To Treat Alcohol Use Disorder A Review of the Research for Adults
Medicines To Treat Alcohol Use Disorder A Review of the Research for Adults Is This Information Right for Me? Yes, this information is right for you if: Your doctor* said you have alcohol use disorder
MOHS MICROGRAPHIC SURGERY
Mary E. Maloney, MD Director Professor of Medicine David E. Geist, MD Assistant Professor of Medicine Dori Goldberg, MD Assistant Professor of Medicine Mark J. Scharf, MD Professor of Medicine Jason D.