|
Date
|
Comments
|
|
Name
|
Procedures Suggested/Reccommended
|
|
DOB
|
Quotes Given By Dr
|
|
Chart Number
|
Procedure(s) Planned
|
|
Area of Concern/Surgery Considering
|
Medications Prescribed
|
|
How long has the patient wanted this for?
|
Risks Discussed
• • •
|
|
Prior Hospitalizations
|
Smoker
|
|
Past Medical History
• • •
|
Labs Needed
|
|
Family History
• • •
|
EKG Needed
|
|
General History
• • •
|
Clearance Letter Needed
|
|
|
Pictures Taken
|
|
|
Photo Consent
|
|
|
Consent Signed
|
|
|
|
|
|
|
|
|
|
|
|
|
|
New Field
|
|
|
|
Comments
|
|
Diagram
|
|
|
Comments
|
|
|
|
Comments
|
|
|
|
|
Notes
|
|
|
|
|
|
|
Assessment/Plan Comments
|
|
|
|
|
|
Notes
|
