Eileen Marie Wayne, M.D.
Board Certified Eye Surgeon
1302 7th Street
Moline, IL 61265
(309) 736-0808



List of Patient Orders I Choose for Myself


So that I may clearly state the content and conditions of my consent to permit medical and surgical procedures, I write my orders at home and bring them to the treatment facility. My orders override any and every blanket consent form I am asked to sign. Make them a permanent part of my medical record and provide me the following choices:

____ I want to receive and keep my informed consent material in written and in audiotape or audiovideotape form.
____ I want a copy of the American Board of [My Required Specialty e.g., Plastic Surgeons] Surgical Criteria for my proposed procedure and all alternative procedures.
____ I want to see a videotape of my proposed procedure in its entirety as performed by my surgeon.
____ I want to talk with a person who has my same condition and has had my proposed treatment.
____ I want to share experiences with someone who has my condition and needs the procedure I had.
____ I want the name and address of the support groups concerning my condition.
____ I want a person of my choice with me at all times during my appointments and procedures including surgery. I empower my person to halt any procedure not fully explained, not authorized, or not smoothly performed.
____ I want a copy of my history and physical examination findings, and my Practitioner's proposed plan of action in lay and in CPT computer terminology, risks and benefits before I sign my legal consent document.
____ I want my right or left body part labeled "CUT" in ink before I sign my legal consent document.
____ I want the descriptive product package insert and full product disclosure information for any implants that are to be permanently placed into my body and for any oral and injected medications I am to receive.
____ I want only positive statements and healing messages said during my procedure, even though I am unconscious.
____ I want first right to examine and keep any and all implants and tissue removed from my body.
____ I want a duplicate set of glass pathology slides of my condition to keep.
____ I want a duplicate of my x-ray pictures and will pay the extra charge.
____ I want the radiologist to explain the pictures to me and will pay the extra charge.
____ I want copies of my typewritten test results.
____ I want every office and hospital encounter audiotaped -- I will bring my own audiotape recorder and audiotape.
____ I want my Legal Living Will and Advanced Directives honored.
____ I want to co-sign any Do Resucitate/Do Not Resucitate, Intubate/Do Not Intubate, or no nourishment by an abnormal route orders.
____ I want adequate medication, with self-administered pump so I will never be in pain.
____ I want a copy of my medical record in its entirety immediately upon request and upon completion of this visit or confinement. I reserve the right to question, correct, and sign approval of my medical record before I authorize release of any information and before it becomes a permanent, public, legal document. I will do so within 30 days. I want my original record given to me, rather than destroyed, when the facility converts to alternative record storage media. If I should die before receiving my records, provide my next-of-kin or legal representative my entire medical record.
____ I want an itemized copy of my bill. I want a copy of each bill that is sent to each insurance company.
____ I want all my patient rights as listed by state and federal law, by the American and my State Hospital Associations.
____ I want only Providers I choose in writing may treat me and I reserve the right to terminate my Provider relationship at any time.
____ I want proof that each of my practitioners is free of AIDS and other infectious diseases.
____ I refuse to allow anyone, not even my Provider, to give consent for me to receive any non-life-threatening procedure while I am rendered unconscious.
____ I reserve the right to refuse medication or treatment and request an AMA form (Against Medical Advice, Against My Advice, Against Mother's Advice) to document my refusals. I understand that my insurance will pay for my treatment even if I sign out AMA.
____ If I am unable to get urgent professional help during a hospitalization, I'll dial 0 for the hospital operator to page the Administrator, Supervisor, and Physician on duty 24 hours and 365 days a year. If all else fails in an emergency I'll dial 911. For less urgent matters, I request a daytime patient advocate and that an "unusual occurence" report be filed.
____ I want redress, within 10 working days of my written grievance, for each and every violation of my orders. I send copies of my grievances to my Practitioner, my facility president, my insurance company, my State and my County Medical Society, the American Medical Association, my State Professional Licensing and Disciplinary Board, the National Institute of Health, The Better Business Bureau, Civil Rights (public accommodations division) Commission, City and State.





Audio-Video Taping Options

So that I may see, hear, and know I am treated with competence, dignity, and privacy, I exercise my option to obtain an audio only or an audio-videotape of my personal procedure in its entirety. I know there is no cost for the taping when I provide my own tape. I want a recording by the following method:

I Choose One:
____ I want an unedited audio and videotape of my procedure in its entirety.
____ I want an edited audio and videotape (before and after only) of my findings before treatment and my results after treatment without recording the actual treatment procedure itself.
____ I want an audiotape only (no videotape).
____ I want no tape (no audio or video) because my Practitioner and/or I are uncomfortable being either audio or videotaped.

I Choose One:
____ I want sole ownership of my tape - no copies.
____ I agree to permit copies of my tape for education purposes.


Signature_______________________________________Date_________

Witness______________________________________________________


Copyright 1998 Eileen Marie Wayne, M.D.

This document may be reproduced with proper attribution to Dr. Wayne printed on each page. It may not be sold for profit, have its meaning altered, or be used to demean any person. Include the web URL address. Mounting online copies elsewhere is not permitted because this document is continually evolving. Links are welcome.


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