ESTABLISHED PATIENT POST-OP INFORMATION SHEET
Patient Information
Patient Name
*
Birthdate
*
Age
Visit Date
*
Please attach a scan or photo of the front of your driver’s license
Referring Doctor
*
Family Doctor
Have you received both COVID-19 vaccinations?
*
Yes
No
Please attach a scan or photo of the front of your vaccination record
Medications
Have any of your medications changed since your surgery?
*
Yes
No
You may either complete the following section or upload a photo of your medication list
Please enter
all
of your medications in order for us to properly treat you.
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Add additional medications?
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Name
*
Dosage
*
Frequency
*
Medication Allergies
Do you have any medication allergies?
*
Yes
No
Medication
*
Reaction
*
Add another Allergy?
Medication
*
Reaction
*
Add another Allergy?
Medication
*
Reaction
*
Add another Allergy?
Medication
*
Reaction
*
Add another Allergy?
Medication
*
Reaction
*
Add another Allergy?
Medication
*
Reaction
*
Latex Allergy
*
Yes
No
Iodine/Contrast Allergy
*
Yes
No
Patient Signature
*
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
*