SURGICAL PATIENT INFORMATION

Please provide the requested information prior to your scheduled surgery. (These forms are not for individual physician practices.)

All required fields are denoted with an asterisk (Required). You may save your progress at any time.

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*This field is required

Mailing Address

Home Details

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PERSONAL INFORMATION

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Employment Details

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Emergency Contact Details

Insurance Details

Insurance Secondary Details

Please provide us the requested information. All required fields are denoted with an asterisk (Required). You may save your progress at any time.

ADDITIONAL PATIENT AND PROCEDURE INFORMATION

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INFORMATION ABOUT SPECIFIC CONDITIONS

Yes No Comments
Seizures / Convulsions
Blackouts / Syncope
Stroke / TIA
High Blood Presure
Heart Attack
Chest Pain(Angina)
Palpitations / Dysrhythmia
A - Fib
Heart Failure
Heart Murmur
Hyperlipidemia
Pacemaker
Asthma / COPD / Bronchitis
Shortness of Breath
Exercise Tolerance
Cold in Last 2 Weeks
Pneumonia
Yes No Comments
Obstructive Sleep Apnea
Ulcers, GERO, Hiatal Hernia
Hepatitis / Jaundice
Kidney Trouble
Diabetes
Thyroid Trouble
Blood Clotting Problems
Sickle Cell Anemia
Anemia(Low Blood)
Pregnant
Back Trouble
Handicap
HIV / AIDS
History of Transfusions
High Fevers with Anesthesia
Family Problems with Anesthesia
Others Problems

Please provide us the requested information. All required fields are denoted with an asterisk (Required). You may save your progress at any time.

Please Enter name of your primary care physician, family physician, internist or pediatrician.

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Do you have any other health care providers who are currently providing services to you?

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Please provide us the requested information. All required fields are denoted with an asterisk (Required). You may save your progress at any time.

1. Patient Rights handout provided?

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Required2. Do you or significant others / care givers(s)have special need or disability?

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*This field is required

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3. May we share your name, general condition, religious affilaltion and room number with those who ask(i.e friends who call, clergy, etc.)?

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Required4. In the event of a medically necessary circumstance, will you accept a blood transfusion or blood products?

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*This field is required

5. Do you have a patient representative/support person?

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a. If YES, name Provide Patient and visitation Rights Handouts to personal representative if present. If not present, provide copy in packet.

b. If inpatient, may we notify your personal representative/friend/family that you have been admitted?

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(PERSONAL REPRESENTATIVE IS PRESENT) if YES or DECLINES, document name date and time of notification:

If UNABLE TO DETERMINE(follow policy and document actions taken in Paragon.Notification of admission Completed.

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If NO, call assigned nurse for follow up and request nurse document notification and document same in Paragon.

6. For EMERGENCY ROOM visits, may we notify your Family Physician that you have been seen in the Emergency Room?

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May we notify your family physician that you have been admitted?

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If YES or UNABLE TO DETERMINE (follow policy to derlermine which physician to notify), list name(s) of doctor(s) notified and document in Paragon.

If NO, enter DNNP in Notes in Paragon.

7. Visitation Rights given

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8. Advance Directive Brochure and From Provided. Document status in Paragon.

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9.Immunization - We report immunizations to the state and Federal goverment (If you would like to optout of the reporting please circle)

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10. Are you participating in a Clinical Research Study?

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11. If first encounter or when updated, provide Notice of Privacy Practices (Entered in Paragon)

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12. If Medicare inpatient, Message of Medicare Rights notice given:

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13. Privacy Password Provided (last 4 digits of account number):

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