Confirmation for upcoming procedure

Confirmation for Upcoming Appointment

Please complete and submit-
Name *

First Name Last Name
Birth Date *

Month Day Year
Type of appointment- If you have multiple appointments select all that apply. *

Telehealth appointment In Person Clinic appointment MRI Injection/Procedure Surgery
I confirm I will be keeping the scheduled appointment. *

Yes No
Do you wish to re-schedule this appointment? *

Yes No, not at this time
Has your pain resolved?

Yes, I am no longer seeking treatment No, my pain has not resolved but I still wish to cancel my appointment
What sedation method do you plan on using?

None Nitrous Oxide Gas (Laughing Gas) Pain Melt (pain & sedation medications by mouth) IV Sedation with Prime Anesthesia Group Nitrous Oxide Gas and Pain Melt
When is the soonest date you would prefer to re-schedule this appointment?

Month Day Year
Date
If you choose to receive any sedation, you will be required to have a driver-- Do you already have a driver arranged?
If you plan on receiving IV Sedation, you will need to call Prime Anesthesia Group at 501-227-0700 to make payment prior to your upcoming injection.
Please note - Failure to bring the imaging on a disc may delay your appointment time and care
If lab work is required for your MRI - Have you obtained your lab work? (Labs are required if the MRI is with contrast and you are over the age of 60.)

Yes No Not Applicable
If you have not yet gotten lab work done, when do you PLAN to do so? *

Month Day Year
Date
Please Note - failure to get lab work before your MRI will delay your care and there is a chance that the MRI might not be able to be performed
Where did you obtain your labwork?
When did you obtain your labwork?

Month Day Year
Date
Have you felt sick, had a fever or taken antibiotics over the past week? *

Yes No
If yes, please explain:
Various medications can increase the risk of bleeding during and after procedures-These medications include, but are not limited to; Aspirin, Advil, Motrin, Ibuprofen, Naproxen, BC Powder, Coumadin, Plavix, Diclofenac, Meloxicam and other NSAIDs or Blood Thinners. Please confirm that you have stopped ALL such Medications. *

Yes, I have STOPPED taking any and all medications that may increase my risk of bleeding I have not yet stopped taking (any or all) of these type medications but will on the instructed date I do not take any of these type of medications
Medication #1 and PLANNED stop date:
Medication #2 and PLANNED stop date:
Medication #3 and PLANNED stop date:
Medication #1 and Date Last Taken:
Medication #2 and Date Last Taken:
Medication #3 and Date Last Taken:
If you are taking Coumadin / Warfarin: You should obtain pre-procedure labs. Have these been done yet? *

Yes No I do not take this medication
Where did you have labs done?
What date were labs obtained?

Month Day Year
Date
When do you plan to get the required labs done?
Where do you plan to get the required labs done?
Have you been vaccinated within the past two weeks? (e.g. COVID, FLU, Shingles) *Steroid injections could lessen the effectiveness of your vaccine. *

Yes No
Confirm that you are aware that receiving a steroid injection could lessen the effectiveness of your recent vaccine. Do you wish to proceed?

Yes, I would like to proceed with my injection as planned No, please contact me to re-schedule my upcoming injection
What is your current pain level out of 10? *Level 10 being the most severe. *

1 2 3 4 5 6 7 8 9 10
Has your pain level or location of pain substantially changed since you last spoke with the APN, Physician or Scheduler regarding this injection/procedure? *

Yes No
How has your pain changed?

Improved - No more pain Improved - I still have enough pain to warrant continuing with my scheduled injection Worsened - I have the same type of pain and in the same location it is just worse Changed- I have the same type of pain it is just in a different location now Changed- I have a different type of pain but it is in the same location
If you are experiencing the same pain but in a DIFFERENT location, please explain WHERE the pain is now located:
If you are no longer in pain and are seeking no additional treatment, would you like to cancel your upcoming procedure? A staff member will be contacting you soon to discuss the most appropriate next steps in your plan of care.

Yes, I would like to CANCEL my upcoming procedure as I am no longer in pain No, I wish to KEEP my upcoming appointment as planned
It is great that your pain is resolved at this time- a member of our staff will be reaching out to you to discuss your plan of care and appropriate next steps!
Have you ever been told you have high blood pressure?

Yes No
Please let us know what your blood pressure is today? *If your blood pressure is elevated too high on the day of your procedure or surgery there is a chance we will need to cancel or postpone.
Have you ever been told you have high blood sugar or diabetes?

Yes No
What is your blood glucose level today? *If your glucose level is too high uat check-in the procedure may be re-scheduled or cancelled
Please note any other issues or topics you feel we may be concerned about in regard to your scheduled procedure:
PLEASE NOTE: THE TIME SENT ON YOUR APPOINTMENT REMINDER IS THE TIME OF YOUR ACTUAL PROCEDURE. A NURSE WILL BE IN CONTACT WITH YOU ONE-TWO DAYS PRIOR TO CONFIRM YOUR ARRIVAL TIME AT THE SURGERY CENTER - Location: 5800 W 10th Street Suite 206, Little Rock, AR, 72204
Please note--- Telehealth appointments are done over the phone via video or calling. If you are unsure if your appointment is telehealth please text us at 501-661-0077 to verify.
Someone from our office will be in contact to discuss rescheduling your appointment.
Should be Empty:

Confirmation for Upcoming Appointment

Please note - Failure to bring the imaging on a disc may delay your appointment time and care

Please Note - failure to get lab work before your MRI will delay your care and there is a chance that the MRI might not be able to be performed

PLEASE NOTE: THE TIME SENT ON YOUR APPOINTMENT REMINDER IS THE TIME OF YOUR ACTUAL PROCEDURE. A NURSE WILL BE IN CONTACT WITH YOU ONE-TWO DAYS PRIOR TO CONFIRM YOUR ARRIVAL TIME AT THE SURGERY CENTER - Location: 5800 W 10th Street Suite 206, Little Rock, AR, 72204

Please note--- Telehealth appointments are done over the phone via video or calling. If you are unsure if your appointment is telehealth please text us at 501-661-0077 to verify.