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Carol Anderson, D.O. Leslie OllarShoemake, D.O. Lisa Waterman, D.O. Daphne Lash brook, M.D. M. Dianne Chambers, M.D. Allison Carter, M.D. Surgery Information Date: / / Patient Name: Clinical Information

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1. Start by gathering all relevant medical records, including test results, previous diagnoses, and any current medications.
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4. Provide a detailed medical history, including any past surgeries, allergies, chronic conditions, or family medical history.
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8. Provide details about any recent hospitalizations or emergency room visits, including the reason for admission and the dates of the occurrences.
9. If you have any preference or special instructions regarding your treatment plan, communicate them clearly in the provided space.
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