ࡱ> q` bjbjqPqP |::H/R  3338@3D4t $44444444XZZZZZZ$-h~E )644)6)6~ 44íI8I8I8)6p 4 4XI8)6XI8I8F 44 /)036d"TX٭0 vK6K"K 8 4"4I85(5444~~7X444 66!6)6 D%/ /  Ingrown Toenail [Onychocryptosis] Removal Partial Side and/or Total Nail] Surgery IDENTIFICATION OF PARTIES Patient Name and SSN: Facility Location, Date and Time: Surgeon[s]: Surgical Procedure: Ingrown toenail surgical removal; with/or without nail bed reconstruction. Will not sterilize or cauterize the matrix-root. Occasionally, cutting and suturing is needed, if severe. Surgical Assistants: Explaining Counselor: Additional Information: OPERATION INFORMATION Diagnosis and Condition: Painful ingrown toenail that may have proud-flesh and a bacterial or fungus infection. Allergies: Anatomic Location: Toe[s]; Right or Left foot; usually big toes; occasionally lesser toenails. Purpose / Benefits: Remove painful ingrown, fungus or bacterial infected toenail or ingrown border-side. Matrix or nail root is not cauterized or sterilized; re-growth will occur. Description of Procedure: Anesthetic (numb toe with 1-2cc's lidocaine/marcaine etc; epinephrine used with caution). Sterile prep with rubber band tourniquet, if indicated. Elevate nail side, resection to proximal nail fold and excision of offending border or total nail. Debridement to drain and clean and dry eponychial toenail sockets. Curette, lavage, bandage and hydrocortisone cream and/or oral antibiotics, as needed, etc. Aftercare with Epsom salt, and/or H2O2 soaks with periodic cleaning until healed. Potential Risks / Complications: Ingrown toenail recurrence, crooked or unsightly appearing discolored toenail re-growth, bone and soft tissue infection and fungus contamination/formation. Care in diabetic patients or those with vascular compromise; toe loss; swollen fat toe and toe/limb loss; persistent RSD pain syndrome. Alternatives to Procedure: Trimming and cutting, soaking, debridement, plastic strips, chemicals; consult with your physician. Recovery and Follow-up Care: Soaks, antibiotics, band aides and bandage changes, as needed. Additional Consent Information: An ingrown toenail may also be removed using a surgical incision "cold steel" tissue and cutting technique with scalpel. Comments: Fungus infestation, if present, is very resistant to treatment and has numerous causes. It is conservatively treated with periodic manual and/or electrical debridement. Medically, oral ultra-micronized oral griseofulvin (0.5 gm QD) may be tried for 6 to 18 months. Other agents such as Sporonox, Lamisil and Diflucan may be used. Oral ketoconazole (200 mg QD) is may also be used for candidal onychomycosis. Avulsion with topical anti-fungal agents may prove useful. Topical PenLac may also be used; along with other oral and topical agents. PATIENT / SURROGATE SIGNATURE AND ATTESTATIONS By signing this consent-form and explanatory process, I or my surrogate, confirm and attest to the following: The procedure and its purpose has been explained to me; including benefits, risks, possible-complications, alternatives, recovery period and follow-up care; in an understandable language without technical terms. I have been told about options, including not having the surgery. All my questions have been answered and my curiosity satisfied. I have read this consent form prior to receiving any anesthetic or mind-altering drugs, and I understand it to my comfort level. I freely elect to undergo this surgery and have this surgical procedure. I understand my doctor may modify the above plan; intra-operatively as needs dictate. I have the legal decision-making capacity for all of the above. Patient Signature: Surrogate-Relationship Signature: Consent Process Counselor: Primary Witness: Secondary Witness: [Required if patient/surrogate signed with an X mark] Comments: OPERATING SURGEONS STATEMENT By signing this consent-form and explanatory process, I confirm and attest to the following: Relevant issues of the surgery have been explained and the patient given the opportunity to ask question about it, including but not limited to: benefits, risks, possible-complications, alternatives, recovery period and follow-up care; in an understandable language void of medical jargon. No threats, inducements or misleading information was used to coerce the patient into surgery and s/he was given the opportunity to review and discuss a printed copy of this consent-form prior to surgery. I have identified the patient, procedure and anatomic location, and reviewed the past medical history, H&P, medications, allergies, chart and progress-notes; and have approved them. I am licensed and capable of performing this surgical procedure, and can document same. No outcomes guarantees were made. Surgeon: Surgeon: Surgeon: Ingrown Toenail [Onychocryptosis] Removal with [Partial Side and/or Total Nail] Permanent Root-Matrix Sterilization and Cauterization IDENTIFICATION OF PARTIES Patient Name and SSN: Facility Location, Date and Time: Surgeon[s]: Surgical Procedure: Ingrown Toenail Removal with Cauterization and/or Sterilization of the Nail Root, and/or with reconstruction of the nail bed/; if needed. An ingrown toenail may also be removed using an incision "cold steel" technique, such as those described by Winograd, Suppan, Polokoff, Kaplan, Zadik, or Frost, and other modifications, etc. CO2 or other lasers may be used. Surgical Assistants: Explaining Counselor: Additional Information: Surgically, an ingrown toenail is usually removed with out an incision; and using phenol, sodium hydroxide, or other chemicals or surgical laser beams for root matrix-sterilization with alcohol technique. Occasionally, cutting and suturing is needed if severe. OPERATION INFORMATION Diagnosis and Condition: Painful ingrown toenail that may have a bacterial or fungus infection. Allergies: Anatomic Location: Any toes; usually the great big toes; Right, or Left foot. Purpose / Benefits: Remove painful ingrown, fungus or bacterial infected, toenail or side. Kill or sterilize the root matrix to prevent/reduce recurrence. Description of Procedure: Anesthetic block (numb toe with 1-2cc's lidocaine/marcaine; epinephrine use cautioned, etc). Sterile prep with rubber band tourniquet, if indicated. Elevation toenail side, resection to proximal nail fold and excision of offending border or nail. Debridement to drain and clean and dry eponychial toenail socket. Chemical matrixectomy with 88% phenol or 10% sodium hydroxide (chemicals, laser, scalpel, 5% acetic acid flush to neutralize the sodium hydroxide). Cotton tipped applicator applied to matrix for until tissue appears destroyed and/or white. Curette, lavage flush, bandage, and hydrocortisone cream or oral antibiotics, as needed. Aftercare with Epsom salt, or H2O2 soaks or similar with periodic debridement, until healed. Potential Risks / Complications: Recurrence, crooked or unsightly appearing toenail, infection and fungus formation. Cauterization is performed with caution in diabetic patients or those with vascular compromise; scar, bone or soft tissue infection; swollen fat or lost toe/leg with nerve or vessel damage; RSD pain syndrome; may need drain removal. Alternatives to Procedure: Trimming, soaking, debridement plastic strips, chemicals and removal without sterilization; consult with your physician. Recovery and Follow-up Care: Soaks, antibiotics, band aides bandage changes. Additional Consent Information [Photographs, video-graphy, etc] Comments: Fungus infestation, if present, is very resistant to treatment and has numerous causes. It is conservatively treated with periodic manual and/or electrical debridement. Medically, oral ultra-micronized oral griseofulvin (0.5 gm QD) may be tried for 6 to 18 months. Other agents such as Sporonox, Lamisil and Diflucan may be used. Oral ketoconazole (200 mg QD) is may also be used for candidal onychomycosis. Avulsion treatment with other topical and oral anti-fungals may prove useful. Topical PenLac may also be used, etc. PATIENT / SURROGATE SIGNATURE AND ATTESTATIONS By signing this consent-form and explanatory process, I or my surrogate, confirm and attest to the following: The procedure and its purpose has been explained to me; including benefits, risks, possible-complications, alternatives, recovery period and follow-up care; in an understandable language without technical terms. I have been told about options, including not having the surgery. All my questions have been answered and my curiosity satisfied. I have read this consent form prior to receiving any anesthetic or mind-altering drugs, and I understand it to my comfort level. I freely elect to undergo this surgery and have this surgical procedure. I understand my doctor may modify the above plan; intra-operatively as needs dictate. I have the legal decision-making capacity for all of the above. Patient Signature: Surrogate-Relationship Signature: Consent Process Counselor: Primary Witness: Secondary Witness: [Required if patient/surrogate signed with an X mark] Comments: OPERATING SURGEONS STATEMENT By signing this consent-form and explanatory process, I confirm and attest to the following: Relevant issues of the surgery have been explained and the patient given the opportunity to ask question about it, including but not limited to: benefits, risks, possible-complications, alternatives, recovery period and follow-up care; in an understandable language void of medical jargon. No threats, inducements or misleading information was used to coerce the patient into surgery and s/he was given the opportunity to review and discuss a printed copy of this consent-form prior to surgery. I have identified the patient, procedure and anatomic location, and reviewed the past medical history, H&P, medications, allergies, chart and progress-notes; and have approved them. I am licensed and capable of performing this surgical procedure, and can document same. No outcomes guarantees were made. Surgeon: Surgeon: Surgeon: About Our Foot Skeletal Drawings and Illustrations Some pundits may ask: Why write something-out, when diagrams are clearer, faster and easier? However, this may not be necessarily true for the increasingly sophisticated informed medical consent communications process, today! Nevertheless, we include some basic skeletal illustrations and diagrams for your consideration regardless of venue. And, theyve been placed in a separate file for your convenience. Incorporate them into your informed-consent process and paperwork whenever you wish; or not! Use our illustrations and diagrams, or substitute your own. Here are some additional suggested multipurpose uses, of our complimentary and value-added illustrations, for your podiatry practice: Patient Education / Screenings: Explain a patients condition and proposed treatment plan, as well as create a written record of what was covered. Surgical Consents: Surgical consent-forms may, or may not contain a diagram of procedures; but illustrations alone are not a substitute for informed-consent communication or documentation. Historically, the written part of the consent was done on the illustration at the bottom of the page. But, if you are using a stand-alone illustration, these diagrams alone may no longer be adequate. In true informed-consent collaborative fashion; patient information, education and customized document preparation is needed. And, e-Podiatry Consent Forms"! increasingly are preferred by some physicians? However, both may be used for additional virtuous reinforcement. Medical Records: Use these illustrations and diagrams when records are size-limited. Disclaimer: These are illustrations and customizable templates. [1] They are not medical advice. [2] Not a standard-of-care. [3] Not a surgical treatment or clinical care plan. [4] Not patient specific. [5] Document production tools are for physician use only. As with all e-Podiatry Consent Forms"!, consult a health-law attorney and/or your malpractice insurance carrier prior to use. Note: You may place our diagrams, or your own illustrations here; prn.     Dr. John Youthful Samples; Jr. DPM  INCLUDEPICTURE "http://healthcarefinancia!"*JQRS˳˛gN6.hQ5B*CJOJQJ^JaJmH phsH 0h hQ5B*CJOJQJaJmH phsH 7h7h05B*CJOJQJY(^JaJmH phsH /h7h05@B*CJOJQJY(aJph/h7hHr5@B*CJOJQJY(aJph/h7h5@B*CJOJQJY(aJph/h7hQ5@B*CJOJQJY(aJph7h7hQ5B*CJOJQJY(^JaJmH phsH *RSmn M N gd$a$gd )$$d%d&d'dNOPQa$gdF9Smn  ? @ E ʯʗʯʯjXFXjF4F#h+B*CJ^JaJmH phsH #hHrB*CJ^JaJmH phsH #h4B*CJ^JaJmH phsH )hL|@hL|@B*CJ^JaJmH phsH .hL|@5B*CJOJQJ^JaJmH phsH .h7&5B*CJOJQJ^JaJmH phsH 4hfhQ5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH :hhQ5>*B*CJOJQJX^JaJmH phsH E F ~    . L ȭȭȭȀbȭMM;M#h+B*CJ^JaJmH phsH )hobhQB*CJ^JaJmH phsH :hhQ5>*B*CJOJQJX^JaJmH phsH 4hhQ5B*CJOJQJ^JaJmH phsH #hQB*CJ^JaJmH phsH 4hfhQ5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH h@B*CJaJph!hh@B*CJaJphL M k l m r s     ҷҢ~eҢSA/#h+B*CJ^JaJmH phsH #hHrB*CJ^JaJmH phsH #h-B*CJ^JaJmH phsH 1hQ5B*CJOJQJ^JaJmH o(phsH #hL|@B*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH )h:hQB*CJ^JaJmH phsH 4hfhQ5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH )h?UhQB*CJ^JaJmH phsH N Y Z n o  ~  n o 4+-[ $d*$a$gd$a$gdJ~$ & F d*$1$7$8$H$a$gdgd " > L m ! " ( . 8 : M S o r x } خsesesh4@B*CJaJphh 0@B*CJaJphh+@B*CJaJphhQ@B*CJaJph!h^ hQ@B*CJaJph.hQ5B*CJOJQJ^JaJmH phsH #h-B*CJ^JaJmH phsH #hIaB*CJ^JaJmH phsH )h:hQB*CJ^JaJmH phsH '   7 ; W _ n o ໣||||gR)hwUhQB*CJ^JaJmH phsH )h+hQB*CJ^JaJmH phsH #h+B*CJ^JaJmH phsH )h+h+B*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH ,hUChQ5B*CJOJQJ^JaJphh+@B*CJaJph!h^ hQ@B*CJaJphhQ@B*CJaJph !+,34<ghشش؜n]L>h-@B*CJaJph!hwUhQ@B*CJaJph!h4hQ@B*CJaJph1h4h4B*CJOJQJ^JaJmH phsH )h4h4B*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH #h B*CJ^JaJmH phsH #h+B*CJ^JaJmH phsH )hwUhQB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH hqst㹢ucuQ?Q#hHrB*CJ^JaJmH phsH #h4B*CJ^JaJmH phsH #hB*CJ^JaJmH phsH )hwUhQB*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH ,hVhQ5B*CJOJQJ^JaJphhQ@B*OJQJphh @B*CJaJphh-@B*CJaJphhQ@B*CJaJphhL|@@B*CJaJph 3Qet ƴo^P^B4B^h@B*CJaJphhQ@B*CJaJphhJ~@B*CJaJph!hdhQ@B*CJaJph.hB5B*CJOJQJ^JaJmH phsH )h05+hQB*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH #hL|@B*CJ^JaJmH phsH #hHrB*CJ^JaJmH phsH )hwUhQB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH ()*+7=IV_`ijwx/Y[\Ĭ㛍e2hhQ5>*B*CJOJQJX^JaJphh@B*CJaJphh4@B*CJaJph!h-hQ@B*CJaJph.hQ5B*CJOJQJ^JaJmH phsH hQ@B*OJQJph!hdhQ@B*CJaJphhQ@B*CJaJphhHr@B*CJaJph[\Qq*bcmn $ & Fa$gdgd$a$gd\q *XYZ[aDzvvvvvvvaJaJa,h{=hQB*CJ^JaJmH o(phsH )h{=hQB*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH #h;B*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH )h hQB*CJ^JaJmH phsH 4h;FvhQ5B*CJOJQJ^JaJmH phsH :hhQ5>*B*CJOJQJX^JaJmH phsH acmn  ҹ|dOOO=#hIaB*CJ^JaJmH phsH )h hQB*CJ^JaJmH phsH /hhQ>*B*CJX^JaJmH phsH =hhQ5>*B*CJOJQJX^JaJmH o(phsH :hhQ5>*B*CJOJQJX^JaJmH phsH 1hHr5B*CJOJQJX^JaJmH phsH 4h^KwhQ5B*CJOJQJ^JaJmH phsH #hQB*CJ^JaJmH phsH n    !+,-./0123456$a$gd $ & Fa$gd$a$gdgd )*+78;?AFHMͻv^^F..hEm5B*CJOJQJ^JaJmH phsH .h 5B*CJOJQJ^JaJmH phsH .hB5B*CJOJQJ^JaJmH phsH .h2v5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH )h hQB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH 4hhQ5B*CJOJQJ^JaJmH phsH 6789:;<=>?@ABCDEFGHIJKLMNOPQR$a$gd MPST\detuv~иqZqB**.hQ5B*CJOJQJ^JaJmH phsH .h5B*CJOJQJ^JaJmH phsH ,h1hQ5@B*CJOJQJaJph&hQ5@B*CJOJQJaJph4h hQ5B*CJOJQJ^JaJmH phsH .hHr5B*CJOJQJ^JaJmH phsH .h 5B*CJOJQJ^JaJmH phsH .hEm5B*CJOJQJ^JaJmH phsH .hI 5B*CJOJQJ^JaJmH phsH RST12>? $d*$a$gdgd)$$d%d&d'dNOPQa$gd$a$gd ʯgI1.hQ5B*CJOJQJ^JaJmH phsH :hhQ5>*B*CJOJQJX^JaJmH phsH .h5B*CJOJQJ^JaJmH phsH .hHr5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH 4h hQ5B*CJOJQJ^JaJmH phsH 1hQ5B*CJOJQJ\^JaJmH phsH 7h hQ5B*CJOJQJ\^JaJmH phsH   =>?QS|͸qcUcqGqGqhQ@B*CJaJphh@B*CJaJphh4@B*CJaJph!hdhQ@B*CJaJph#hQB*CJ^JaJmH phsH #hB*CJ^JaJmH phsH #h4B*CJ^JaJmH phsH )hwUhQB*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH 4hfhQ5B*CJOJQJ^JaJmH phsH ;?BEFHJKU\ĩĩĩĆuguguguYgugKgYgugKh4@B*CJaJphhIa@B*CJaJphhQ@B*CJaJph!hwUhQ@B*CJaJph!hwUhQ@B*OJQJph#hQB*CJ^JaJmH phsH 4hfhQ5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH )hwUhQB*CJ^JaJmH phsH hQ@B*OJQJph   !"+;X\ҷfQ?Qf*)h:hQB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH )hobhQB*CJ^JaJmH phsH 4hfhQ5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH :hhQ5>*B*CJOJQJX^JaJmH phsH 4hhQ5B*CJOJQJ^JaJmH phsH hQ@B*OJQJph!hwUhQ@B*CJaJphhQ@B*CJaJph  !"yz) a!!"s"t"$d*$1$7$8$H$a$gd4$ & F d*$1$7$8$H$a$gd$a$gdJ~gd $d*$a$gdV< &'8T[elxؕؕؕrdrdVdrHhIa@B*CJaJphh4@B*CJaJphhQ@B*CJaJph!h^ hQ@B*CJaJph#hIaB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH 1hQ5B*CJOJQJ^JaJmH o(phsH .hQ5B*CJOJQJ^JaJmH phsH )h:hQB*CJ^JaJmH phsH #h;B*CJ^JaJmH phsH  ; A K M ` f ! ! !!'!`!a!!!!!!!!!!!!!!!?"J"r"s"t""""Ҟw#hQB*CJ^JaJmH phsH )hwUhQB*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH h;@B*CJaJphhQ@B*CJaJphh4@B*CJaJphhIa@B*CJaJph!h^ hQ@B*CJaJph."""""""""""G#I#O#o#z############wwiR,hwUhQ5B*CJOJQJ^JaJphhQ@B*OJQJphh;@B*CJaJphhQ@B*CJaJphhL|@@B*CJaJphh @B*CJaJph!hwUhQ@B*CJaJph.hQ5B*CJOJQJ^JaJmH phsH #hQB*CJ^JaJmH phsH )hwUhQB*CJ^JaJmH phsH t"##g$h$$$$$$%%'''E'F'''(( )))+* $ & Fa$gd2v $ & Fa$gd$a$gd$a$gdV<gd#$ $$'$H$f$g$$$$$%%%"%X%Y%%%*&+&4&5&B&C&&ƴƜۇyhZhyhLhyhyhyhh|@B*CJaJphh4@B*CJaJph!h-hQ@B*CJaJphhQ@B*CJaJph)h05+hQB*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH #hL|@B*CJ^JaJmH phsH )hwUhQB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH #h|B*CJ^JaJmH phsH &&&&&&&&&& ''''''E'F'V'ມhM8)h hQB*CJ^JaJmH phsH 4h;FvhQ5B*CJOJQJ^JaJmH phsH :hhQ5>*B*CJOJQJX^JaJmH phsH 4hQ5>*B*CJOJQJX^JaJmH phsH 1hQ5B*CJOJQJX^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH hQ@B*CJaJph!h-hQ@B*CJaJphh;@B*CJaJphV'^'c'f'}')+*k*l*************++++++'+~g~g~L4h^KwhQ5B*CJOJQJ^JaJmH phsH ,h{=hQB*CJ^JaJmH o(phsH )h{=hQB*CJ^JaJmH phsH 4h;FvhQ5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH #h2vB*CJ^JaJmH phsH )h hQB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH +*k*l**********++'+(+F+G+++,,-L..$a$gdEm $ & Fa$gdgd $ & Fa$gd'+(+9+:+E+F+G+W+_+d+g+~+++,,.ŦŎ|g|g|g|U|C|#hEmB*CJ^JaJmH phsH #hL!+B*CJ^JaJmH phsH )h hQB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH /hhQ>*B*CJX^JaJmH phsH =hhQ5>*B*CJOJQJX^JaJmH o(phsH :hhQ5>*B*CJOJQJX^JaJmH phsH 7hhQ5B*CJOJQJX^JaJmH phsH ............................$a$gd $a$gd.........//// /-/:/;/ͻvdR@+@+@+@(hvhc3}5B*CJ OJQJaJ ph"hc3}5B*CJ OJQJaJ ph"hEm5B*CJOJQJaJph"hQ5B*CJOJQJaJph.hB5B*CJOJQJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH )h hQB*CJ^JaJmH phsH #hQB*CJ^JaJmH phsH .hQ5B*CJOJQJ^JaJmH phsH 4hhQ5B*CJOJQJ^JaJmH phsH ....../////////;/=/?//"0#0$[$\$a$gdc3}$a$gdc3})$$d%d&d'dNOPQa$gdc3}$a$gdX F$a$gd ;/=/?/L/P/U/V/h/i/l/m/|///////000"0#0111111111ƴƠƴƴƴƴƴƴrƴ])hc3}5B*CJOJQJ\^JaJph,h _hc3}6B*CJOJQJ^JaJph,hhc3}6B*CJOJQJ^JaJph&hc3}6B*CJOJQJ^JaJph#hc3}B*CJOJQJ^JaJph)hV!fhc3}B*CJOJQJ^JaJphh=l`hc3}5CJOJQJaJ(hvhc3}5B*CJ OJQJaJ ph#0s1t111122#6$6{6|6888{ 50p@ P !$gdA [$\$gdA$ & F&-DM [$\$a$gdc3} & F&[$\$gdc3} [$\$gdc3}$ & F&[$\$a$gdc3}$[$\$a$gdc3}122U2V2g2h2k22222222222222222L3M3\3|33333333333332545ҽҫ},hhc3}6B*CJOJQJ^JaJph,hV!fhc3}B*CJOJQJ\^JaJph#hc3}B*CJOJQJ^JaJph)hV!fhc3}B*CJOJQJ^JaJph)hc3}5B*CJOJQJ\^JaJph/hV!fhc3}5B*CJOJQJ\^JaJph)4565b5d5f5#6$63666;6=6?6N6g6l6r6x6y6z6|66oZC,hqrhc3}5B*CJOJQJ^JaJph)hc3}5B*CJOJQJ\^JaJph/hV!fhc3}5B*CJOJQJ\^JaJph)hV!fhc3}B*CJOJQJ^JaJph#hc3}B*CJOJQJ^JaJph#hc3}B*CJOJQJ^JaJph)h& hc3}B*CJOJQJ^JaJph,hhc3}6B*CJOJQJ^JaJph&hc3}6B*CJOJQJ^JaJph666666666-7K7e7i777777888 888&8(8P8Z8r8888ŵŵŵŵŵŵŞucŵŵŵŵ#hc3}B*CJOJQJ^JaJph)h& hc3}B*CJOJQJ^JaJph&hc3}6B*CJOJQJ^JaJph,hhc3}6B*CJOJQJ^JaJphhc3}B*CJOJQJaJph%hqrhc3}B*CJOJQJaJph#hc3}B*CJOJQJ^JaJph)hqrhc3}B*CJOJQJ^JaJph8888888888 99990929<9D9F9H9L9N9R9T9X9Z9^9b9xxgXPLPLPLPLHh|Nhw=jhw=UhAhAB*CJaJph hAhc3}6B*CJaJphhAh AlB*CJaJphhAheB*CJaJphhAhc3}B*CJaJphhAhxB*CJaJphhEmB*CJaJphhAB*CJaJph+hAhA5>*B*CJOJQJaJphhc3}CJaJ)hV!fhc3}B*CJOJQJ^JaJph8F9J9L9P9R9V9X9\9^9`9b99OPQRS$a$gd  $ } a$gd{ $ } a$gdhgdAb9d999:KNORSrs{|ȼȲ|hAhAB*CJaJphhw= h h|N5B*OJQJphh|N5B*OJQJphh|Nh|NmH sH Uh|NB*mH phsH jh|NB*UmH phsH (h zh|N5B* CJOJQJaJph"h|N5B* CJOJQJaJphls.files.wordpress.com/2008/02/bio-mathewjohn-img2.gif" \* MERGEFORMATINET  ePodiatryConsentForms.com and iMBA Inc. All rights reserved. USA Not a treatment or care plan. Not the standard of care. For Physician template use only. gdAz+p,p-p.p1h/R 4567:p{/ =!"#$% (Dd  c A ?http://healthcarefinancials.files.wordpress.com/2008/02/bio-mathewjohn-img2.gifbVXVoOMDnVXVoOMPNG  IHDR+)K PLTEݽǛqZzT˾bCsFҰŦΝN@0~pְ輻׿; pḎq~G˪zӗj‹)!xbT׵iSDtěybɱŤ{fF(zެȽΦb՜nUݼͬm{Y6rN׮yaēK2#մfffPư˴T@,wȤrר|Sܶ̒pGͦ{ٰs\Ip•դm ̤zmg̯dQ?ᦚsMΛYf3ЯmM1ε̸cbE/ߴݶִT}X^LtRNSbKGDHgIFg>U cmPPJCmp0712Hs[IDATHK]WH` [BDYA[AQ3cMX4Tj ڲkѿJ잽9'$/$x<qӌ_,4ݰ8ӷ |9:!D] _]RE4rA.>v[>fs:[(:py쯛챳H2 " ?yNA2d åM,$I"96ՐZk rFƶccPĨ;kl[Ub]a% $FD]T f[Ĺ[ BiK֚:-L)lMɌγcfCU*/9!@1?uFg&}͸{_8TR0ֱ F[KהJZJ-kcnxid1JAQ3MKa;E3 b}5#W}[ 7N`WN3B]'xgYÇm.j/y)8%}F?71D^mmMw-]RڳT-%re\IM~e꾘j6 ]h72{d wNo޴;ζops<,tDht-53Uc!<;|dS[S%1'h\ 0hq8y+9+`CI"v+\,K UhwnݱLcl HIF02ݛQۖ(d_!Yd5linwABsINC럮W/ z0~IENDB`H@H Normal CJOJQJ_HaJmH sH tH R@R Q Heading 1$<@&5CJ KH \^JaJ p@p Q Heading 2#$$d*$1$7$8$@&H$a$ 5@B*CJOJQJaJphN@N Q Heading 3$<@&5CJ\^JaJR@R  Heading 4$<@&5CJOJQJ\aJN@N Q Heading 5 <@&56CJ\]aJDA@D Default Paragraph FontRiR  Table Normal4 l4a (k(No List4@4 d Header  !4 @4 d Footer  !*W@* S VStrong5\4U@!4 S V Hyperlink >*phR^@2R xq Normal (Web)dd[$\$CJOJQJaJ<OA< gRfont12CJOJQJ^JaJo(NOQN Dcontent1%56CJOJQJ\]aJo(ph>Oa> rstyle11CJOJQJ^JaJo(hB@rh Q Body Text$d*$1$7$8$H$a$@B*CJOJQJaJph:0@: Q List Bullet  & F>6@> Q List Bullet 2  & FN>@N QTitle$<@&a$5CJ KH\^JaJ HC@H QBody Text Indenthx^hFJ@F QSubtitle$<@&a$ CJ^JaJPOP paragraph1^CJ_HmH sH tH DZ@D Plain TextCJOJQJ^JaJ0*RSmnMNYZno~no4+-[ \  Q  q *bcmn    !+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRST12>?  !"yz)astghEF !!!+"k"l""""""""""##'#(#F#G###$$%L&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&''''''''';'='?''"(#(s)t))))**#-$-{-|-.//H/J/K/M/N/P/Q/S/T/V/y/////;00000000000000000000000000000000000 0 0 0 0 0 00000000000000000 0 0 0 0 0 0 0000000000000000000 0 0 0 00000000000000000000000000000000000000000000000000000000000000000000000000000000 0 0 0 0 0 0 0 0 0000000000000000000 0 0 0  0  0  0  0 000000000000000000 00 0 0 00000000000000000000000000000000000000000000000000000& 00& 00& 00& 0000@0I00@0I00@0I00@0I00I00 @0@0@0I0 0 ,@0@0@0@0I00I00 R~n+[ + )&#-$-{-|-./H/y//0@0@ 0=@ 0=@ 0=@ 0=@ 0 =@ 0 =@0=@0=@0= @0@0=@0=@ 0=@ 0=@ 0=@ 0=@ 0 =@ 0 =@0=K00 @0K00K00 @0K00K00 @0 0K00K00 0 MOQTSE L  h\a M"#&V''+.;/14568b9 !"$%&'()+,.02345789;<=?ACEFGHJN [n6Rt"+*..#08#*-/16:>@BDIM1TC Dg{ 70700:0:00V*urn:schemas-microsoft-com:office:smarttagsplacehttp://www.5iantlavalamp.com/_*urn:schemas-microsoft-com:office:smarttagscountry-regionhttp://www.5iantlavalamp.com/ [u0'0 etH/H/J/J/K/K/M/N/P/Q/S/T/00H/H/J/J/K/K/M/N/P/Q/S/T/003*QnFon  6T""&&,$-H/H/J/J/K/K/M/N/P/Q/S/T/00H/H/J/J/K/K/M/N/P/Q/S/T/00'TuJV Sk Ծ0T dzm$; @ CEH:=X.P(*!rЙ(xx(*i.7 |T!"{+:~KRD. rQ38R0D_aiFPIMTkpJ,0L"5NLx?R| U~ IQUd,WyX j'MYҖpHYP~8q[]\>^fgr {hx8y0ZAy.Z q~nW ^`OJQJo( hh^h`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(hhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(hhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(hhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(oh^`OJQJo(hHh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo('rQ3~8q[HYfgj'MYyX0T 8yAyRD.q~*X.P!IEH Ck 0L\V "{+5N| U.7 0D {hWkpJm!rLx?RxxaiF IQU''                                                                                                                                                                                                                                                                                                                                             Jw6 b]  +A |.RJ<  V'A Tz5Y"9"/Rj4KT.E` lX7ed "&)4},/RHDa,.K_o[/]/}qe3X|~ 4x@N56*h8 b1lMbH|0YW.fQK 0 KU`H]bu g ]O m  k $ I d lS a@zb7k&(*NA!-;sc:d<<A)7YIl K2vdy{ 9we9M^o&F^,@!z|! "P$W4%iQ%t%}%7&`&+''''f'k' (+()B){) y*+L!+;,l8,nQ,?[, b,jT.x.C/)h/0 0F0=W0v0*1B192Tc2_T3454u45"5 m56O6Y7 47w7x70^8e8|89$9>`9E,:?;Av;W7<QT<V<6X=w={= >h*>j>t>0W?x?L|@2~@AGAkpAvBy!C2C*CCOICFX F)FWFRlFD#G%`GxG]H%HI7nI,SJ[J/%K2LjMTqM|NO-O\5OLOkO$2P7PQPlP Q|QHRC]RTM]TtUUtEUXUtUS VVV@WMWWZWX4zX4FY,/ZTZ.\{ ^s^{^___`_H` x`Ia3atDaGb[bRcdee"e/eSeQfif+gfWghjjtj Al)SlZlcl^mNmvmn\n oo8oebobpZq&rqxq,rn-r9rHrpr{rW sksn#sXs`stsYMt )u;utu;Fv^KwDwoDx y)y+yKy z#z{D0{E{#| +|zK|c|^/}c3}:I}L}Jq}Ft}J~T"gw|o!n=[; %CQ}xNQc~`C(~?zHJV{{~U2nfx!9=SZf 74;s`hqjzlMgR,8EVvg%-]n"39 =WW3;Q+SO[flHuP%>f&>Xwz} *7>TIc|%bhx\\P H%UNFOMdo<-F[]|  ~6l|x$)5[m2K#0c=YD}K2\2_j~:DxN{+aroDc<FcJ@KkyJ^NP'+4^cr R2v.e|]B6`-=^Qa it1HgjG^ 0Z%Y+NYa!"]"uAwyn RN *U0[: Z6Dw 3 G8JP #mV=~12wn 3Tcu pZr?3&>Y g7A\m?,W M 7-%QEmal \+r8yt|7|y~u#7 98lpv{2bz`1Zg@IIh=II@,-./0@@@4@l@@8@0@UnknownGz Times New Roman5Symbol3& z Arial=Arial BoldqTimes New Roman BoldTimes New RomanA& Trebuchet MS?5 z Courier New;Wingdings"1hxʦxʦʆ:(U:(U(΂!4d0/0/ 2qHX ?tU$In"Dr. David E. Marcinko; MBA CFP CMP"Dr. David E. Marcinko; MBA CFP CMP'                           ! " # $ % & Oh+'0  8D d p | In$Dr. David E. Marcinko; MBA CFP CMPNormal$Dr. David E. Marcinko; MBA CFP CMP2Microsoft Office Word@@P$@x0@x0:(՜.+,D՜.+,\ hp  0Institute of Medical Business Advisors, Inc.U0/ In Title  8@ _PID_HLINKSAx)LPhttp://healthcarefinancials.files.wordpress.com/2008/02/bio-mathewjohn-img2.gifH   !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNPQRSTUVXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry Fp90Data O1TableWWordDocument|SummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q