2835 W. De Leon Street, Suite 205
Tampa, FL 33609
TEL (813) 831-6622 FAX (813) 874-1936
Notice to Examinee for Independent Medical Examination
We would like to inform you that you have been referred to our clinic for an INDEPENDENT MEDICAL EXAMINATION ONLY. This differs from other doctor visits you may have because this is an Independent Medical Examination regarding your injuries for your accident, and is usually accomplished in only one visit to our clinic. You will not be established as a patient at our practice. All treatment recommendations are to be followed through with your healthcare provider. If you do not have a healthcare provider, we urge you to seek one immediately.
What will you experience today:
The physician will listen to you carefully, take a detailed history and examine you. However, because this is an Independent Medical Examination, any diagnosis, treatment recommendations, medication prescriptions, referral to other healthcare providers or facilities for treatment, or any other treatment, care or other information regarding your medical treatment or condition will be your responsibility to follow through with, utilizing your current healthcare provider or another healthcare professional of your choice.
I have read and understand the above information, and I UNDERSTAND THAT THE PHYSICIAN, ROSANNA GARNER, M.D. or KIMBERLY TOBON, D.O., THAT IS PERFORMING MY INDEPENDENT MEDICAL EXAMINATION IS NOT MY TREATING PHYSICIAN.
I UNDERSTAND THAT I MUST THEREFORE SEEK TREATMENT OR CONTINUE TREATMENT WITH MY CURRENT HEALTHCARE PROVIDER, OR ANOTHER HEALTHCARE PROVIDER OF MY CHOICE, FOR ANY AND ALL MEDICAL NEEDS I MAY HAVE.