Patient's Name:

Patient's Age:    

Patient's Sex (male/female):    

Daytime Phone Number:  

Height:

Weight:

Name of Surgeon During Procedure:

What Procedure are you having done?:

Date and Time of Procedure:

Please list any medications you are currently taking, as well as the dosage information (example, Tylenol 4 times a day):

Do you take Flomax? (yes/no) :

Are you on a blood thinner? (yes/no) :

Are you currently insulin dependent? (yes/no) :

Are you taking any diet drugs? (yes/no) :

Are you taking any herbal remedies? (yes/no) :

Do you have any known allergies? (yes/no) :

Are you allergic to latex? (yes/no) :

Have you experienced any productive cough over two months, unexplained weight loss, or night sweats? (yes/no) :

Have you or any relatives had any problems with anesthesia? (yes/no) :

Could you be pregnant? (yes/no) :

Have you had any blood drawn, urine, or any other lab work recently done? (yes/no) :

Have you had an EKG done in the past month? (yes/no) :

If so where?:

Do you Smoke? (yes/no): *if you do, DO NOT smoke the morning of surgery

Do you drink alcohol? (yes/no) :

If yes, how much do you consume on a daily basis? :

Do you wear dentures? (yes/no):

Do you wear glasses or contact lenses? (yes/no):  
*If you wear contact lenses, please bring your container and solution, contacts will need to be removed.

Do you wear hearing aids? (yes/no):

Do you have an Advance Directive? (yes/no):

TRANSPORTATION/CARETAKER

We cannot do your surgery unless you have someone to drive you home and stay with you until the following morning.
Who will be bringing you?:

Patients up to 18 years old: It is MANDATORY that a parent or guardian remain in the facility during the procedure and recovery time. Please check the boxes next to the following information stating you are aware.

        Wear comfortable and loose clothing. A button up shirt MUST be worn.

        Please do not wear jewelry.

        You must bring in your insurance cards so we can copy them for correct billing information.

        Copayment will be collected prior to surgery (if applicable). If you are not sure if you have a deductible or copay, please call                  the surgery center.

        Please bring with you any Pre Op drops as instructed by your surgeon's office.

        Please bring your walker or crutches with you if you are dependant on them.