Mesh Consultation Information

MESH CONSULTATION INFORMATION
Name

First NameLast Name
Date of Birth
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Best Time to Contact You
MANDATORY QUESTIONS TO BE ANSWERED

Surgical History
Year
Procedure
Physician
Year
Procedure
Physician
Upload Medical Records (main records of importance – OPERATIVE REPORT(S) AND/OR PATHOLOGY
Browse Files

Cancelof
If you do not have your medical records, please fill out the Medical Records Release Request on the next page
Previous attempted mesh revision/removal surgeries?

YesNoN/A
Do you currently have any cough, sneeze, laugh urinary leakage? *

YesNoN/A
Sexually Active *

YesNoN/A
If Yes, is sexual intercourse painful *

YesNo
If NO, is there a physical/medical reason you are no longer sexually active?
If YES, can you describe the pain and the location of the pain to the best of your ability.
When sexually active, has your partner been scratched during intercourse? *

YesNoN/A
Have you experienced any recurrent bleeding or infections?

YesNoN/A
To the best of your ability, please describe your current symptoms and/or pain that you are experiencing.
Did your pain begin immediately after surgery?

YesNoN/A
If not, when did your pain begin?
Does anything cause your pain to increase?
Does anything help to relieve the pain?
Do you have any major medical problems we should be aware of?
Desired Surgical Timeline?

0-3 months6-9 months9-12 months
Desired Location?

AtlantaBeverly HillsDubai
MEDICAL RECORDS

If you do not have your medical records available, please fill out the fields below to authorize us to request your medical records.
AUTHORIZATION TO RECEIVE MEDICAL RECORDS
Patient Name

First NameLast Name
Date of Birth
Social Security#
Name and Address of Physician Sending the Medical Records
The above named physician(s) are hereby authorized to release to:

John R. Miklos, MD and Robert D. Moore, MD
I,
Your Name
hereby authorize the above named facility/physician to release my medical records, including any psychiatric, alcohol or drug abuse information. Specifically, the following:
Type of Reports

Laboratory ReportsPathology ReportsPsychiatric NotesHistory / PhysicalOperative ReportsRadiology ReportsSpecial Diagnostic Reports (EKG, EEG, etc)Discharge SummaryOther
Other Type of Report
The information is needed for the following purpose (check all that apply)

Continued care by the receiving facility/physicianClaims settlement with insurance companyNeeded to receive aid by the above named agencyLegal proceedings or advisePersonal UseOther
Other Purpose
SIGNATURE: (This authorization is valid for a period of 90 days from the date signed) I have read and understand this Consent for Release of Medical Information, and have voluntarily and knowingly signed such consent.
Signature

Clear
Date
Atlanta Office ~ 11975 Morris Road ~ Suite 140 ~ Alpharetta, GA 30005

Beverly Hills Office ~ 9201 West Sunset Boulevard ~ Suite 406 ~ West Hollywood, CA 90069

Main Phone: 770-475-4499 Fax: 678-585-2705 www.miklosandmoore.com
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MESH CONSULTATION INFORMATION

MEDICAL RECORDS