CONFIDENTIAL PATIENT INFORMATION

 

- Please Print -                                                         DOB: __________________  SSN:__________________________    

 

NAME: _______________________________________________    DATE:____________  TIME: ___________

               LAST                                 FIRST                                       MI

 

ADDRESS: _________________________________________________________________________________

                      STREET                                                                CITY                                            STATE                      ZIP

 

PHONE: ______________________________________________________        COUNTY: _________________    

                HOME                         WORK                              CELL

 

Inside city limits? YES / NO   Have you been to this clinic before? YES / NO  If yes, when? ____________________

 

Age: _______ Name of OB/GYN doctor: ________________________ Last menstrual period:_________________

 

Height: _____________ Weight: ______________ Marital status: ________________________ Sex: _________

 

Nearest relative: __________________________        How did you hear about us? _________________________

 
THE FOLLOWING INFORMATION IS FOR STATISTICAL PURPOSES:

RACE	RELIGION	EDUCATION	ORIGIN OR DESCENT
ASIAN	BAPTIST	0-12:	AFRICAN
BLACK	BUDDHIST	COLLEGE: 1-9:	CHINESE
HISPANIC	CATHOLIC		ENGLISH
NATIVE AMERICAN	CHRISTIAN		FRENCH
WHITE	HINDU		IRISH
OTHER	JEWISH		KOREAN
	MUSLIM		MEXICAN
	OTHER		OTHER

 

REGARDLESS OF THE TYPE OF ANESTHESIA YOU RECEIVE WITH YOUR PROCEDURE, YOU WILL NEED A RESPONSIBLE ADULT TO ACCOMPANY YOU ON DISCHARGE. Even with minor procedures, there is always the possibility that you could experience a anesthesia side effect after leaving the office. For this reason you MUST HAVE A RESPONSIBLE ADULT TO ACCOMPANY YOU UPON DISCHARGE OR WE CAN NOT PERFORM YOUR PROCEDURE TODAY. Your total stay time at the office will take about 3-5 hours. The adult with you is free to leave after checking you in and should return about the time you will be ready for discharge.

 

In the rare event that the accompanying adult leaves the office and does not return, the patient will be required to remain under observation in the office for at least two (2) times the normal post-procedure period. At that time, the physician will be consulted with regards to the discharge of the patient. Upon his disposition, the patient may be sent home in a taxi with the patient being responsible for the charges incurred in this transport.

 

I have read the above statement. I have arranged for a responsible adult to accompany me from the office after discharge.

 

Patient signature: __________________________________________________     Date: ___________________

I have read the above statement. I have agreed to be the responsible adult who accompanies the patient from the facility after discharge.

Responsible Adult's Signature: ________________________________________   Date: ___________________

PATIENT- Nothing By Mouth Statement - Complete this statement on the day of your surgery.

I have not had anything to eat or drink including water, gum, or mouth mints since midnight last night. If you did eat or drink, what did you eat or drink? ____________________________________Date: __________Time: ___________

Patient's Signature: ____________________________________________________________