Part 1 Patient Print v1

Part 1

Surgeon information
Physician name*
Dr. Ronald Smith
Email*
Ensure accuracy - this is where your manuscript will be sent!
Best contact number*

Part 2

Practice information
Practice name
Daytime Practice Phone Number
Please enter a valid phone number.
After Hours Practice Phone Number
Please enter a valid phone number.
Website
Fax Number
Please enter a valid fax number.

Clinic address #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add a second clinic location

YesNo
Clinic address #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add a third clinic location

YesNo
Clinic address #3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add a fourth clinic location

YesNo
Clinic address #4

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Surgical Location #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add a second surgery location

YesNo
Surgical Location #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add a third surgery location

YesNo
Surgical Location #3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add a fourth surgery location

YesNo
Surgical Location #4

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Office hours
Monday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Tuesday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Wednesday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Thursday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Friday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Weekend hours

ClosedOpen SaturdayOpen Sunday
Saturday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Sunday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option

Procedure
Surgical approach
Average surgical duration
Typical anesthesia

Scheduled medications

	Medication	Dose	Frequency	Duration	Notes
1.
2.
3.
4.

As-needed medications

	Medication	Dose	Frequency	Duration	Notes
1.
2.
3.
4.

Other information about your procedure you would like to highlight in the book
Should be Empty: