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SURGERY FORMS

SECURE ONLINE PRE-REGISTRATION FORM


Patient's Name:
Physician's Name:
Date of Procedure:
Procedure
Patient's Legal Guardian &
Relationship to Patient:
Email Address:
PREFERRED CONTACT INFO:
Contact Name
Phone - Home:   Work:  Cell:
INFORMATION REGARDING THE CHILD:
DOB of Child:   Age of Child:  Gender:Male< Female
 Language:English Spanish
ALLERGIES:
Drug/Reaction:
Food/Reaction:
Latex/Reaction:
Other:
ANESTHESIA:
Does your child or family have a history of problems with anesthesia?
Yes No Explain:
MEDICAL HISTORY:
Does your child have a history of any of the following?















Loose Teeth - Which?
- List Name & Phone:

Explanation/Comments:
SURGICAL HISTORY:
Has your child had previous surgery or been hospitalized?
Explain:
IMPAIRMENTS/DISABILITIES/SPECIAL NEEDS:
Explanation/Comments:
MEDICATIONS:
Current Medication(s
(Prescribed and Over the Counter):
Any medication(s) instructed to take
day of surgery:
OTHER:
Immunizations Up To Date: Yes No
Exposure to Flu or Chicken Pox
in the last 7-21 days?
Yes No
Spiritual/Cultural Needs: Yes No
Explanation/Comments:
You MUST check this box to affirm you have read the Patient Bill of Rights: Yes, I have read the Patient Bill of Rights and ownership list.
  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.