INSTRUCTIONS: ALABAMA PROCEDURES USING LASERS OR OTHER MODALITIES AFFECTING LIVING TISSUE ADVERSE EVENT REPORT FORM

If Alabama medical procedures using lasers or other modalities affecting living tissue result in an adverse event, this document should be filed. This form can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 1: On the first blank line, enter your name.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 2: On the second blank line, enter your Alabama license number.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 3: On the third blank line, enter your street address, city, state and zip code.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 4: On the fourth blank line, enter your specialty as a physician.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 5: On the fifth blank line, enter the date of the procedure.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 6: On the sixth blank line, enter the type of procedure.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 7: On the seventh blank line, enter the type of device or modality used.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 8: On the eighth blank line, enter the name and title of the person performing the procedure.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 9: On the ninth blank line, enter the date of the procedure.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 10: On the tenth blank line, specify what the adverse event was.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 11: Indicate with a check mark whether the patient was hospitalized and what the outcome was.

Alabama Procedures Using Lasers Or Other Modalities Affecting Living Tissue Adverse Event Report Form Step 12: Provide a brief narrative description of what occurred, then sign and date the form.