Patient Forms

History and Physical Form

All patients who are receiving anesthesia (other than local) are required to have this form completed by their Primary Care Physician. History and physical must be completed within 30 days of scheduled surgery.

Depending on your age and medical conditions you may be required to have additional tests, like an EKG, chest x-ray or blood work. This is outlined on the form for your physician.

It is usually a good idea to make sure that your doctor gives you a copy of the completed form for you to bring with you to the surgery center.

Many doctors will fax us the completed form, but having your own copy will avoid delays on the day of surgery.

IMPORTANT: If you have a pacemaker or implantable defibrillator, another special form is required to be completed by your cardiologist. This form is available from your surgeon’s office.

Medication List

Medications can often effect your anesthetic and surgical outcome.

This packet includes a form on which you are asked to list ALL medications that you are currently taking. This includes over-the-counter and herbal supplements, as they can have effects on anesthesia, bleeding and healing just like prescription medications.

This type of list is something you will be asked to supply, in the future, to any hospital, surgery center, physician’s office.

We will be glad to make you a copy of your own.