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