Patient Name

:
Chart Number:




Your doctor also has an ownership interest in the Great Plains Surgical Distributorship
which supplies orthopedic implants that may be ordered for your surgery.


Please feel free to discuss any questions regarding this notice with your doctor.




Patient Signature: _________________________________________


Date:





















Form 125 – Implants Ownership (03/14
Orthopedic Surgeons
M.J . Adler, MD
K.M. Baumgarten, MD
W.O. Carlson, MD
R.B. Curd, MD
E.N. Hermanson, MD
T.D. Howey, MD
D.C. J ohnson, MD
M.C. J ohnson, DO
D.B. J ones, J r., MD
P.A. Looby, MD
M.J . McKenzie, MD
C.P. Rothrock, MD
R.C. Suga, MD
E.S. Watson, MD
T.M. Zoellner, MD


Interventional Pain
Management
J .T. Brunz, MD

Physical Medicine
K.C. Chang, MD





Outreach Clinics
Brookings, SD
Creighton, NE
Freeman, SD
Huron, SD
Madison, SD
Marshall, MN
Mitchell, SD
Rock Rapids, IA
Rock Valley, IA
Sibley, IA
Spirit Lake, IA
Tyndall, SD
Wagner, SD
Yankton, SD
NOTICE TO PATIENTS
DISCLOSURE OF PHYSICIAN OWNERSHIP
GREAT PLAINS SURGICAL DISTRIBUTORSHIP
COMPREHENSIVE ORTHOPEDIC CARE
SPINE CENTER · SPORTS MEDICINE CENTER
UPPER EXTREMITY CENTER
FOOT & ANKLE CENTER

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