 |
 |
|
|
 |
DOCTOR'S CLINICAL IMPRESSION |
|
REASONS FOR CLINICAL IMPRESSION |
|
RECOMMENDATIONS |
|
SURGICAL INDICATIONS |
|
OPERATIVE TREATMENT |
|
FEE AND INSURANCE |
|
NO GUARANTEES WARNING |
|
POST-OPERATIVE ACTIVITIES |
|
CONVALESCENCE AND REHABILITATION |
|
TREATMENT DEFERRAL |
|
PROGNOSIS |
|
POSSIBLE FURTHER TREATMENT |
|
ADMINISTRATIVE DETAILS |
|
FORMS FOR PATIENT AUTHORIZATION |
|
AREAS FOR PERSONAL COMMENTS TO PATIENT AND REFERRING DOCTOR |
|
|