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. *
Required
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. *
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A copy of your responses will be emailed to the address you provided.
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