Please read, sign and return this form before your surgery:
Correct Patient Information
It is very important that you make sure we have your current address and phone numbers so that our office and the facility can reach you. Cell phone numbers are always helpful. At times there will be changes in the surgery schedule and/or it might be necessary to contact you regarding your lab work or medications before surgery. Your cooperation in this matter is greatly appreciated and will help to eliminate any problems that may result in not being able to reach you. Failure to respond to phone calls regarding your procedure may result in your procedure being cancelled.
Consent Forms
It is mandatory that we have your completed and signed consent forms returned to our office at least 7 days prior to your surgery. Failure to return your forms may result in your surgery being cancelled and/or rescheduled. If your procedure is scheduled close to the date of service, we may need to either communicate them through fax, or you may need to come into the office to sign them.
FMLA/Disability Papers
Please bring any paperwork that needs to be completed in at least 2 weeks before your surgery in order to give your doctor time to fill them out and get them back to you before your surgery date. There will be a $31.00 fee for this service which must be paid prior to us filling out your paperwork.
Reminder Calls
You are to go by the information given to you by our office surgical coordinator. If there are any changes regarding your surgery, either our surgical coordinator or the surgical facility will contact you. If you wish to cancel your procedure, please contact the surgical coordinator at our office. The surgery center will be calling you to register you with their facility, review your medical history and go over insurance and payments that may be due at the time of service. If you do not have online access, please call the number on the front of the surgery center brochure to register with a live person.
These instructions have been reviewed with me by the surgical coordinator and I understand the above information. I also acknowledge that I have received all information pertaining to my surgery.
X_______________________________________ X_______________
Authorized Signature (Patient or Legal Guardian) Date
Please print this page, sign and date it and bring it with you to your next appointment
