May 22, 2003 - Arizona Medical Board
Medical Consultant Report and Summary
Case No: Physician:
Date: Medical Consultant:
1. Detailed (Chronological) Analysis:
2. Proposed Standard(s) of Care:
3. Deviation from the Standard of Care:
4. Actual Harm Identified:
5. Potential Harm Identified:
6. Aggravating Factor(s):
7. Mitigating Factor(s):
8. Consultant’s Summary:
9. Records Reviewed:
______________________________ _______________________
Print Name Date
______________________________
Signature
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