In this time of rapidly expanding medical knowledge and the increasing specialization associated there within, there exists a very real risk of the specialist physician not being aware of the general health and medical background of the patient. On occasion such information may critically affect what procedures we may safely undertake on you and under what circumstances. We therefore ask that you give us the following medical information.
Please select Yes indicating the following that you are currently or have ever been treated for and No for never:
In which surgical procedure(s) are you interested? (Please check)
In the course of consultation and discussion with Dr. Prysi, I may have been shown or may be shown or provided certain brochures, and/or pictures on an electronic computer imaging device. I understand that those pictures and alteration of those pictures seen are solely for the purpose of illustration/discussion and to provide improved communication with the doctor. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics and health. I further understand and acknowledge that because of the obvious significant differences in how living tissues react to surgery, there may be no relationship between the electronic images created, and my actual final surgical result.
Use of the computer imaging system offers an opportunity for me to discuss my desires and to allow an improved communication with the doctor.