Safeguard Plus

Required Patient Summary Application Form

For Those Wishing To Use The Services Of The Lamb Pain Clinics

This Confidential* Patient Summary application form is essential for The Lamb Pain Clinic physician to understand your unique medical history and current needs. Only those who fully complete this form can be considered for consultation. This is another step to ensure the best possible result from your medical review. We will verify your personal and physician contact information. Only those persons with a published home phone number and an ISP email address can be considered (not alias/vanity addresses like Hotmail).

Before you can be considered for a medical review, you must complete the following forms. We need to know your medical history as well as your current medical condition and concerns.

This review must be completed every 12 months to keep current with your changing health needs. IF YOUR HEALTH INFORMATION CHANGES SIGNIFICANTLY, PLEASE NOTIFY IASIS TO UPDATE YOUR FILE.

Your application form will be processed within 3-5 business days. You will then be advised by email that you are eligible to participate in the services of The Lamb Clinics.

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Please provide the following contact information.

All information except Work Phone is required.

About You

Your First Name

Your Last Name

Street Number

Street Name

Suite / Apt #

City

State/Province

Zip/Postal Code

Country

Work Phone Area Code

Work Phone

Home Phone Area Code

Home Phone

Year Of Birth (e.g. 1950)

Sex

Weight (specify lbs. or kgs.)

Height (specify feet/inches e.g. 5/10. or cm.)

Your base E-mail address
(not Hotmail or another alias email address.)

About Your Doctor

Your Dr.'s First Name

Your Dr.'s Last Name

HMO/Practice Corporate Name

Your Dr.'s Street #

Street Name

Suite #

Your Doctor's City

Your Doctor's State/Province

Your Dr.'s Phone Area Code

Your Dr.'s Phone Number

Your Dr.'s FAX

I am 18 years of age or older.

I agree to become a Patient of Ontario for the purpose of this or other medical consultations and agree to be bound by the rules and regulations and laws governing this.

I have read and agree to the Terms & Conditions found in the Legal section of this website.

Are you pregnant?

Are you nursing?

I understand that if approved, I will be charged a non-refundable annual fee of $25 to participate in this program.

Check off any of the medications you take:

Coumadin or Warfarin
Heparin
Asperin
Non-steroidal-anti-inflammatories (NSAIDS) e.g.. Naprosyn, Vioxx, Celebrex
Heart Medication
Seizure Medication
Blood Pressure Medication
Cancer Medication or Chemotherapy

List the prescription medication that your doctor (s) have prescribed:

List the over-the-counter (OTC) medication that you take regularly:

Do you suffer from any of the following PAIN conditions?:

Osteoarthritis
Rheumatoid Arthritis
Any other Arthritis
Fibromyalgia
Myofascial Pain Syndrome
Tendonitis
Bursitis
Back pain
Neck Pain
Degenerative Spinal Disease
Herniated Disk
Carpal Tunnel Syndrome
Patellofemoral Syndrome
Temporomandibular Joint Disease or TMJ
Rotator Cuff Injury
Repetitive Strain Injury

Have you ever suffered from any of the following MEDICAL conditions?

Heart Disease
High Blood Pressure or Hypertension
Migraine Headache
Arthritis (any kind)
Cancer
Anemia
Asthma
Emphysema
Lung disease
Male or Female Fertility Problems
Chronic Pain (any kind)
Depression
Suicidal
Hallucinations or Delusions
Peptic Ulcer Disease
Irritable Bowel Syndrome
Inflammatory Bowel Disease (Crohn's Disease, Colitis)
Kidney Disease or Failure
Diabetes
Liver Disease
Hepatitis (any kind)
Drug or Alcohol Addiction
Chronic Skin Disease or Open Sores
Chronic Penile or Vaginal Discharge
Chronic Infections (any kind)
Glaucoma or other Eye Disease
Bleeding Disorder
Chronic Nose Bleeds, Rectal Bleeding, Blood in Urine

List all of your allergies:

List all of your operations or other reasons for hospital visits:

List all of your pain problems:

Anything else you want the doctor to know?

Type Your First & Last Name To Confirm Agreement.

	About You
Your First Name
Your Last Name
Street Number
Street Name
Suite / Apt #
City
State/Province
Zip/Postal Code
Country
Work Phone Area Code
Work Phone
Home Phone Area Code
Home Phone
Year Of Birth (e.g. 1950)
Sex
Weight (specify lbs. or kgs.)
Height (specify feet/inches e.g. 5/10. or cm.)
Your base E-mail address (not Hotmail or another alias email address.)
	About Your Doctor
Your Dr.'s First Name
Your Dr.'s Last Name
HMO/Practice Corporate Name
Your Dr.'s Street #
Street Name
Suite #
Your Doctor's City
Your Doctor's State/Province
Your Dr.'s Phone Area Code
Your Dr.'s Phone Number
Your Dr.'s FAX