TO TREATMENT Sample Clauses

TO TREATMENT. As a consenting adult and/or legal guardian, I agree to permit the physicians and staff at Dermatology San Antonio to provide medical care to myself, my child or the patient I represent, as applicable. By signing below, I agree to permit the physician and staff at Dermatology San Antonio to perform necessary or appropriate medical care including physical examination, diagnosis, photographing area of assessment and treatment.

TO TREATMENT. I understand that the treatment to be received by me at Aspire Pain Medical Center will be administered only upon full and complete disclosure of benefits, potential risks, and complications of said treatments, and that my informed consent to the treatment to be received by me will not be obtained prior to my receiving said treatment. Each of the physicians working at Aspire Pain Medical Center uses his or her independent medical judgment when providing you with medical care. The physician seeing you is responsible for the medical care you receive at Aspire Pain Medical Center. I declare under penalty of perjury under the laws of the State of California that I have read the foregoing, that I understand it, and that by executing this document on this day of , 201 , in the City of Newport Beach, I accept and agree to its contents. Patient’s Signature Date of Birth Print Name Date Parent/Guardian Date Name: Date: Medication Information Please indicate if you are taking any of the below medications and what the dosage/frequency is: Generic Name Brand name Dosage ☐Buprenorphine Buprenex ☐Butorphanol Stadol ☐Codeine ☐Fentanyl Abstral, Actiq, Fentora, Onsolis ☐Hydrocodone Vicodin, Norco ☐Hydromorphone Dilaudid, Dilaudid-5, Dilaudid HP, Hydrostat IR, Exalgo ☐Levorphanol Levo-Dromoran ☐Meperidine Demerol ☐Methadone Dolophine, Methadose Astramorph PF, AVINZA, ☐Morphine Duramorph, Xxxxxx, MS Contin, MSIR, Oramorph SR, Rescudose, Roxanol ☐Nalbuphine Nubain ☐Oxycodone OxyContin, Roxicodone ☐Oxymorphone Numorphan ☐Pentazocine Talwin ☐Propoxyphene Cotanal-65, Darvon ☐Tapentadol Nucynta ☐Tramadol Rybix, Ryzolt, Ultram Additionally, if you are taking any Benzodiazepines (for example, Valium, Xanax, Ativam, Klonopin, etc.) please indicate below which medications as well as the dosage and frequency: Name Dosage Frequency Please indicate the same for any oral muscle relaxants (for example Soma, Flexeril, etc.) you are taking: Name Dosage Frequency Oswestry Disability Questionnaire Name: Date: This questionnaire has been designed to give us information as to how your pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem.