Center for Athletic Medicine - Surgical Consultation Form
Please complete this form after watching the surgical consultation video. You will not be able to proceed with surgery until we have this form completed.
Email address
I confirm that I have watched the surgical consultation video in its entirety. I feel prepared for surgery and know who to contact for questions any questions I may have.
I will be attending physical therapy at:
The name and phone number of the doctor completing my preoperative clearance is:
Your answer
If you do not have a primary care doctor and would like help finding one, please check this box below.
Electronic Signature - please type your full name to certify that the information above is correct.
Your answer
Name of MINOR having surgery (Parent or guardian name in electronic signature line above).
Your answer
For further questions please call the office at: 773-248-4150.
A copy of your responses will be emailed to the address you provided.
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