Confirmation for Upcoming Appointment
Please complete and submit-
Name
*
First Name
Last Name
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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?
Please Select
Yes
No
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.
Submit
Should be Empty: