Clinical Forms

Clinical Forms

In order to support hemorrhoid banding at your practice, the following documents are provided for download. Those documents marked with a blue “W” are available for download in Microsoft Word to facilitate the use of your own letterhead and customized content.

Patient Handouts

Informed Consent
Post-Band Patient Instructions
Patient Education – Nitroglycerin Ointment
Patient Questionnaire
Fiber Supplements
Treatment of Pruritus Ani/Rashes
Anal Fissures

Clinical Staff Documents

Chart Note
Abbreviated Chart Note
Super Bill (ICD-10)
Prescription Medication Sheet
Information for Cross Covering Physicians
Billing Information
Procedure Note Template
Clinical Pearls
Policy and Procedure Guidelines

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