CHOOSE ONE OPTION:
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REQUIRED
STOP!!
DID YOU HIGHLIGHT
ONE CITY/DATE ??
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What is Your Diagnosis?
Note about Foot Drop:
The surgery that Dr. Nath does
for foot drop, MUST be done
within 6 months of the start
of the problem.
Note about Nerve Tumors:
Dr. Nath does not do surgery
on tumors that are on the spine
and rarely on the skin. You must
come to your appointment with
an MRI in hand.
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REQUIRED
which side?
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If your injury was birth related - check which applies to you:
Was there shoulder dystocia?
Were forceps used for this birth?
Was a vacuum extractor used for this birth?
Was there a c-section performed?
Was there Horner's Syndrome (droopy eye)?
Birth Weight
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FIRST Name of Patient
REQUIRED |
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LAST Name of Patient
REQUIRED |
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Date of Birth & Age
REQUIRED |
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Parents' Names
REQUIRED (if under 18) |
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Address Line One
REQUIRED |
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Address Line Two
City/State/Zip or Country
REQUIRED |
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Main Email
REQUIRED & MOST IMPORTANT |
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Secondary Email
REQUIRED & MOST IMPORTANT |
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| Date of Injury & Injury History |
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Current Additional Therapies
Select only the things that you are
currently involved in - not activities
that you once did some time ago.
For example:
If you did serial casting 3 years ago,
then do NOT check mark it.
But if you are doing it this month,
then checkmark it.
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SURGERY HISTORY - please list only the related surgeries you've had for your peripheral nerve issue.
List surgeries done by Dr. Nath and by other physicians as well.
PLEASE FILL THIS IN COMPLETELY - EVEN IF YOU ARE ALREADY A PATIENT OF DR. NATH
Dr. Nath cannot bring his office files to an Outreach Day, so we need this information
to create a file
for your appointment.
ABREVIATIONS: (if your surgery is not listed here, don't worry - just put a short name below and then
describe it further down where there is more space.)
PR = primary
NT = nerve transfer
MQ = mod quad
TT = triangle tilt
HO = humeral osteotomy
FO = forearm osteotomy
M Rel = muscle release
M
Trfr = muscle /transfers
CTR = carpal tunnel release |
IL = Ilizarov procedure
FGT = forearm gracillis transfer
BTL = biceps tendon lengthening
CAPS = shoulder capsulodesis
WCAPS = wrist capsulodesis
ACR = anterior capsule release
Acromio = acromioplasty
Other = please describe
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REQUIRED FIELD FOR EVERYONE PLEASE
Surgical Procedure 1
Age or Year
Surgical Procedure 2
Age or Year
Surgical Procedure 3
Age or Year
Surgical Procedure 4
Age or Year
Surgical Procedure 5
Age or Year
Surgical Procedure 6
Age or Year
Surgical Procedure 7
Age or Year
Surgical Procedure 8
Age or Year
Are you an existing patient or a new patient?
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Appointment Preference
Check the site page to see if this is
an event that is morning only, afternoon only,
or evening only.
Do not purchase air tickets unless you
check with the coordinator first to make
sure that the Outreach Event or Clinic
Day is still going to happen.
Some events are canceled
as a result of low number of registrations.
tnpiclinics@gmail.com
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Please
check your email accounts frequently for updates and for notice when the
appointments are posted and especially the week before the event or clinic.
Appointments will sent to you by email approximately two weeks before the Outreach Day
or clinic day
.
Clinic Coordinator can be reached at tnpiclinics@gmail.com
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BY HITTING THE SUBMIT BUTTON, YOU ARE LETTING US KNOW THAT YOU HAVE INTENTION TO COME TO YOUR APPOINTMENT AND THAT YOU HAVE READ AND UNDERSTOOD THE FOLLOWING NOTE FROM DR. NATH.
Please note that Dr. Nath makes every attempt to be at scheduled events on time and on the dates scheduled. However, many unforeseen circumstances can and do arise that will alter any plans that are made. Dr. Nath regrets any inconveniences that may be caused if last-minute cancellations or alterations occur in his schedule and he hopes you will be understanding if this happens. No guarantee or warranty of any type is implied by having a scheduled visit canceled for any reason.
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