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DO NOT DOUBLE-SIDE FORMS Rev. 07/2013 DO NOT STAPLE FORMS Page 1 of 3 SDMC Form 220-B SURROGATE DECISION-MAKING COMMITTEE PROCEEDING FOR THE REVIEW OF THE NEED FOR SUPPLEMENTAL MEDICAL INFORMATION Declaration SDMC Use Only Patient s Name ALL QUESTIONS MUST BE ANSWERED TO PREVENT A DELAY IN PROCESSING THE CASE 1a. Current medications dosages frequency and mode of intake 1b. List any drugs requiring frequent blood level monitoring. Include copy Any known allergies Annual physical examination Must include copy Date Abnormal findings Most recent EKG Include copy if available Most recent Chest X-ray Most recent laboratory tests Has there been a second opinion If so what type Capacity Best Interest List any cardiac or pulmonary condition s List any major illness surgery and/or hospitalizations in the last year List any other known physical conditions Has this patient had general anesthesia before Date of most recent general anesthesia Any history of adverse reactions to general anesthesia Yes No Unknown IV sedation and MAC are not considered general anesthesia for SDMC cases. If yes describe MHL Article 80 requires the patient to be present at the hearing. Is there any medical condition that would prevent the patient from attending the hearing If yes explain Is the requested procedure s scheduled If yes date If no when is the anticipated scheduled date Has the patient been reviewed by SDMC previously If yes answer the following if known a* Procedure s previously requested c* b. Results of procedure s If the patient has been transferred to a healthcare facility other than their residence please provide the following information Facility Name Facility Address Facility Contact Person Name Contact s Phone Patient s Room 16. The above information and statements are to the best of my knowledge truthful and complete. Print Name Clearly Signature Title Work Phone Work Fax Work Cell PLEASE REMEMBER TO ATTACH Consults progress notes annual physical exam results of diagnostic tests and other documentation related to the proposed major medical treatment s being requested*. List any drugs requiring frequent blood level monitoring. Include copy Any known allergies Annual physical examination Must include copy Date Abnormal findings Most recent EKG Include copy if available Most recent Chest X-ray Most recent laboratory tests Has there been a second opinion If so what type Capacity Best Interest List any cardiac or pulmonary condition s List any major illness surgery and/or hospitalizations in the last year List any other known physical conditions Has this patient had general anesthesia before Date of most recent general anesthesia Any history of adverse reactions to general anesthesia Yes No Unknown IV sedation and MAC are not considered general anesthesia for SDMC cases. If yes describe MHL Article 80 requires the patient to be present at the hearing. Is there any medical condition that would prevent the patient from attending the hearing If yes explain Is the requested procedure s scheduled If yes date If no when is the anticipated scheduled date Has the patient been reviewed by SDMC previously If yes answer the following if known a* Procedure s previously requested c* b.

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