Secure Online Pre-Registration Form Secure Pre-Registration Form Preinscripción español English Pre-registrationΔPatient's NamePhysician's nameProcedureDate of procedurePatient's legal guardian & relationship to patient: If legal guardian do you have paperwork? Yes NoYour email addressPreferred Contact InfoContact namePrimary phonePhone 2Phone 3Information Regarding The ChildDOB of childAge of childGender Male FemaleLanguage English Spanish ASL OtherAllergiesDrug allergy/reactionFood allergy/reactionLatex allergy/reactionOther allergies/reactionAnesthesiaDoes your child or family have a history of problems with anesthesia? Yes NoDoes anyone in the family have malignant hyperthermia? Yes NoExplainMedical HistoryDoes YOUR CHILD have a history of any of the following?Check all that apply Murmurs/Heart Disease Respiratory/ RSV/Asthma/Pneumonia/Bronchitis Sleep Obstruction/Apnea/Snoring Diabetes Liver, Kidney Urinary Disease Bleeding Disease/Clotting Disorder Muscle, Bone, Joint Disease Syndromes Premature Birth Stomach Reflux Constipation/Diarrhea Skin Disorders/Wounds/Scabies/Rashes Tubes / Drains / Shunts Difficulty Speaking/Swallowing/Eating Nervous System Disease / Seizures / Febrile Seizure / Neurological Deficit / Disorders Loose Teeth Under Care of SpecialistIf premature how many weeks at birth?If your child has loose teeth, which teeth?NICU stay? Yes NoIf yes to any above please explainSurgical HistoryHas YOUR CHILD had previous surgery or been hospitalized? Yes NoExplainImpairments/Disabilities/Special NeedsPlease check any impairments Vision Hearing Speech Ambulation Developmental DelayDoes your child require accommodations?MedicationsCurrent Medications (Prescribed and Over the Counter)OtherExposure to Hand Foot and Mouth Disease Yes NoIf yes, when was the diagnosis date?Immunizations up to date? Yes No If immunizations not current, please explainTravel outside US in the last 30 days? Yes NoExposure to Chicken Pox in the last 21 days? Yes NoSpiritual/Cultural needs Yes NoExposure to Flu in the last 10 days? Yes NoExplanation/CommentsCovid 19Have the PATIENT AND/OR ACCOMPANYING ADULTS traveled outside the U.S.A in the last 14 days? Yes NoIf Yes, dates of travel and locationHave the PATIENT AND/OR ACCOMPANYTING ADULTS been in close contact with a person known to or suspected to have COVID-19? Yes NoIf Yes, dates of contactIn the past 48 hours, have the PATIENT AND/OR ACCOMPANYING ADULTS had any of the following Symptoms: Fever (99.6ºF or higher) or Chills Cough Fatique (Tiredness) Shortness of Breath or Difficulty Breathing Muscle or Body Aches Headache Sore Throat Congestion or Runny Nose Nausea or Vomiting Loss of Taste or Smell Rash on Skin or Discoloration of Fingers or Toes 3 or More Episodes of Diarrhea in the past 24 hours None of theseGI Cases ONLYMy child is having a colonoscopy and we have received instructions for prep Yes NoOvernight Stays ONLY Overnight Policies We have read and understand the instructions regarding overnight staysBelow Required For All Submissions If you have not done so, please click here to review. Please note that reviewing this information is required before arriving for surgery to ensure surgery proceeds as scheduled.You MUST check this box to affirm you have read the Patient Bill of Rights I have read the Patient Bill of RightsSubmit Form
