It's a simple process…

Please be forthcoming with your responses. All of your medical information is confidential.

  • The time it takes to complete the form is dependent on your personal medical history. Typically, a person who is healthy and not taking many medications should expect to spend 15 minutes completing the form. Someone with a more complicated medical history or list of medications will take longer.
  • Upon receipt of your information, a staff member or nurse may call you for further clarification if necessary.

NOTE – You do not have to fill out a form again if you are returning to the same medical facility and have already completed this online form prior to a previous visit. A nurse or staff member will call you to discuss any changes in your medical history since your last visit.

* If you fill out the registration form online in its entirety (address, emergency contact responsible party, spouse or guarantor information, etc) then you will NOT need to fill out the patient registration form that is in the Surgery Center booklet they were given at the doctor’s office.

What will I need?

Before you begin the online admissions form, please make sure that you have the following information available, as it may be needed to complete your form:

  • Prescription medications – names and dosage of each one you take.
  • Over-the-counter medication – names and dosage of each one you take regularly.
  • Vitamin and herbal medications - names and dosage of any that you take.
  • Allergies/Sensitivities you have, and the allergic reaction(s) they cause.
  • Previous surgeries, and the year they were performed.
  • Medical Insurance – insurance company, policy number, ID number, etc
  • Another item - not ideal...

New Patient

For new patients, or if you wish to start a new form, please enter the password that was provided to you by your medical facility:
Enter Password Here:

Returning Patients

If you'd like to resume, modify, or review an existing form please enter the secured access token provided by the Surgery Center and your date of birth.