Supraspinatus Release Consent Form
Please complete this form to provide your information and consent for the supraspinatus release procedure.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Female
Male
Non-binary
Prefer to self-describe
Prefer not to say
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Procedure Details and Clinical Information
Affected Shoulder/Side
*
Left
Right
Both
Unsure
Primary Diagnosis or Reason for Supraspinatus Release
*
Referring Clinician or Provider Name
First Name
Middle Name
Last Name
Procedure Date and Time
Pre-Procedure Notes or Instructions Acknowledgement
Reviewed pre-procedure instructions
Confirmed medication and fasting guidance
Arranged transportation if needed
Other
Medical History and Safety Screening
Allergies
Current Medications
Prior Shoulder Injuries or Surgeries
Current Symptoms and Duration
Conditions Affecting Recovery or Procedure Planning
Consent, Acknowledgement, and Signature
Patient Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: