Patient Registration Form

All information is confidential. Please answer honestly to assure the best possible treatment for you. Please complete steps 1 - 4, you may move freely between them below. You can submit the form on the last step.

Patient Information













Personal Diagnoses
Surgical History

     
Family History
Father:
Deceased    Living









Mother:
Deceased    Living









Brother:
Deceased    Living









Sister:
Deceased    Living









Father's Father:
Deceased    Living









Father's Mother:
Deceased    Living









Mother's Father:
Deceased    Living









Mother's Mother:
Deceased    Living









Personal History
Yes No Frequency
Exercise
Drink Alcohol
Use of Illegal Drugs
Tobacco Use/Smoke
Menstrual Periods


Pregnancies

Question Yes No
Have you ever had an allergic reaction to latex?

Do you or a family member have Malignant Hyperthermia (rapid increase in body temperature and muscle contractions during anesthesia)?
Do you have an allergy to Succinylcholine (muscle relaxant used with anesthesia)?
Do you have an internal defibrillator, pacemaker, neuro-stimulator or stent?





Have you or a blood relative had an unusual reaction to either a general anesthesia or local sedation?
Have you ever had active Tuberculosis or been treated for latent/preventative tuberculosis?
Are you diabetic?







Medications

Please complete this medication list and list of allergies/reactions. Please transfer your medication list to this sheet. This will help us to more efficiently serve you when you come for your office appointment. Thank You!

Medication Name Strength Frequency Reason for taking Medication
Medication Allergies
Medication Allergies Reactions to Medication
Financial Policy

Thank you for choosing Southern Indiana Surgery, Inc. to provide your surgical care. We are committed to providing high quality care to you and your family. The following will outline our financial policy. If you should have questions or concerns regarding our financial policy, please feel free to discuss them with our Practice Manager.


Thank you for your understanding of our Financial Policies. Please let us know if you have any questions or concerns. Please check the box below to agree.

I agree to the financial policy outlined above.
Account Number:
Signature:
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