Treatment plan
Diagnosis: _____________________________________________________________________
Based on the physical examination completed and patient symptoms the best recommended treatment
plan to achieve the greatest success would be:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________
Likelihood of success with the above treatment plan is: ( ) GOOD ( ) FAIR ( ) POOR
By signing this I understand that this is the best treatment plan to achieve optimal results for my
diagnosis based on my health history and physical examination.
If I choose not to have these procedures performed, or choose not to comply with all parts of the
treatment plan I understand that my prognosis is unknown.
Date:______________
Signature of patient or responsible person:_______________________________
Provider signature:___________________________________________________