TESTIMONIAL LETTER CONCERNING THE PAIN TREATMENT
OF
______________________
I am writing to describe my impressions of the pain management in this patient whom I have had contact with ___ times over the last ____________ .
1. Relationship to patient: ____________________.
2. Length of time known: ____________________.
3. Condition prior to treatment:
Work: ____________________________________________________.
Sleep: ____________________________________________________.
Relationships: _____________________________________________.
Mood: ___________________________________________________.
Mobility: _________________________________________________.
4. Improvements noted with treatment:
Work: ____________________________________________________.
Sleep: ____________________________________________________.
Relationships: _____________________________________________.
Mood: ___________________________________________________.
Mobility: _________________________________________________.
5. Comments:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
I agree to notify Dr. __________ if I become aware of any problems developing from patient's treatment, such as abuse of medications or other substances, or if I change my mind, or have any reservations about the benefits of this treatment. I also agree to notify the doctor if I become aware of any improper or illegal activity involving this patient's treatment, such as giving, lending, or selling of medications, or if I become aware of any such activity involving Dr. ___________ practice or any of his patients.
__________________ _________________________
(Date) (Signature)
Comments/Opinions
Frank B. Fisher, MD
[email protected]
510-233-3490
Or
[email protected]
