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.
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:
Center for Athletic Medicine Physical Therapy
Not yet decided, I will call the office with my location.
I am not sure! Please give me suggestions on PT Clinics.
The name and phone number of the doctor completing my preoperative clearance is:
If you do not have a primary care doctor and would like help finding one, please check this box below.
I would like help finding a doctor for my preoperative clearance.
Electronic Signature - please type your full name to certify that the information above is correct.
Name of MINOR having surgery (Parent or guardian name in electronic signature line above).
For further questions please call the office at: 773-248-4150.
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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