Surgery Registration Form

I. Patient Information:
Last Name: A value is required.
First Name: A value is required.
Physical Address: A value is required.
City: A value is required. Zip: A value is required.Invalid format.
   
Mailing Address:
(If different from physical)
City: Zip:
   
Home Phone: A value is required.Invalid format. Work Phone:
Date of Birth: A value is required.Invalid format. Required.
Email Address: A value is required.Invalid format.
Social Security:
Required.
 Required. Please select a valid item. (for reporting purposes only)
Employer: Occupation:
   
II. Primary Care Physician:
Primary Care Physician:
Physician's Address:
City: Zip:
Physician's Phone:
   
III. Next of Kin/Closest Living Relative:
Last Name: A value is required.
First Name: A value is required.
Address:
City: Zip:
Relationship to Patient: A value is required.
Phone: A value is required.Invalid format.
   
IV. Person to Notify in case of emergency (other than next of kin):
Last Name: A value is required.
First Name: A value is required.
Address:
City: Zip:
Relationship to Patient: A value is required.
Phone: A value is required.Invalid format.
   
V. Insurance Information:
Insurance Company: Phone:
Street Address:
City: Zip:
Name of Policy Holder:
Last Name:
First Name:
Policy Number:
Group Number:
Policy Holder's Employer: Phone:
   
Secondary Insurance: Phone:
Street Address:
City: Zip:
Name of Policy Holder:
Last Name:
First Name:
Policy Number:
Group Number:
Policy Holder's Employer: Phone:
   
VI. Responsible Party:
Patient under the age of 18?
If "Yes," please continue. If not, go to Section VII.
   
Parent or Responsible Party's Relationship to Patient:
Last Name:
First Name:
Phone:
Social Security:
Date of Birth:
Address of Responsible Party's (if different than minor)
Address:
City: Zip:
Employer: Phone:
VII. Work Information:
Is this work related?
If "Yes," please continue. If not, go to Section VIII.
   
Supervisor or Contact Name:
Last Name:
First Name:
Supervisor Phone:
VIII. Reminders/Others:

Please remember to bring the following items with you:

  • All insurance, Medicaid, and Medicare Cards
  • Photo ID
  • Co-insurance and deductibles

Before you come in for a surgical procedure:

  • You will be scheduled for a pre-assessment visit
  • You will be given pre-operative instructions specific to your need
  • You will be informed where & when to arrive for your procedure
  • Arrange for someone to take you home following your procedure.
  • Bathe or shower on the morning of surgery to minimize the risk of infection.
  • Wear loose, comfortable clothing and low heeled shoes to the hospital.
  • DO NOT eat or drink the night before surgery (this includes aspirin, herbs, gum, water, mints, or vitamins)
  • DO NOT consume alcohol prior to surgery
  • DO NOT smoke prior to surgery
  • DO NOT wear jewelry or valuables to the hospital
  • DO NOT wear contact lenses into surgery
  • DO NOT wear makeup or nail polish to the hospital

[ *Please consult your physician regarding specifics of these instructions. Additional guidelines may apply to your case.]

Phone Number where we can reach you if we have further questions:
Best time to call you:

Comments/Suggestions:

IX. Help With This Form:
   
If you have questions or need assistance while completing this form, please contact our Patient Coordinator at: 501-520-2000