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    • "Thanks for giving John such good care. We appreciate your service and will ask if you will do it again in a year"
    - Jeanne H.
    *special needs patient.
    Listed below are two methods for submitting the pre-appointment information. You can either: 1) print the pdf version of the form, fill it out by hand, and mail or fax it to us, or, 2) fill out the online form and click "submit" to send it to us by e-mail.

    [ Medical History Form - Adult ]

    Use this form if you wish to print out a PDF of the form and fax it to our offices.

    (Adobe Acrobat Reader required)
    click here to download)

    OR

    Use this form if you would like to fill out the form Online and have it sent via email to our offices. You will need to print out the additional PDF file and bring it with you to your appointment.

    [ Medical History Form - Pediatric ]

    Use this form if you wish to print out a PDF of the form and fax it to our offices.

    (Adobe Acrobat Reader required)
    click here to download)

    OR

    Use this form if you would like to fill out the form Online and have it sent via email to our offices. You will need to print out the additional PDF file and bring it with you to your appointment.

    Medical History Form - Pediatric

    Medical History Form - Pediatric [ Online Form ]

    Filling out the online form is a simple two step process.
    Step 1 - fill out the web form below.
    Step 2 - click on the link for "Patient Instruction Sheet - Pediatric" and print the document.


    Step 1
    Patient Name:   Wt:

    This form is to be completed and returned to our office at least one week prior to the day of your child's procedure. All information is essential to insure your child's comfort and safety, and will be held in strict confidence. None of this information will be released without written permission from you. If you need additional space for your answers, please use the back of this form.
    1)  Please list all past surgeries and child's age when they were performed.
    2)  Has your child or anyone in your family ever had a problem with an anesthetic? Yes  No
    If so, explain:
    3)  Has your child had any allergies, sensitivities, or adverse reactions to any medications? Yes  No
    If so, explain:
    4)  List all medications which your child is currently taking.
    5)  Does your child have a history of heart problems? Yes  No
    If so, explain:
    6)  Has your child ever been diagnosed as having a lung disease (incl. asthma, TB, pneumonia, etc.)? Yes  No
    If so, explain:
    7)  Does anyone smoke inside your house? Yes  No
    8)  Has your child had a recent cold or cough? Yes  No
    9)  Does your child have a history of kidney disease? Yes  No
    If so, explain:
    10)  Does your child have a history of liver disease (hepatitis, jaundice, etc.)? Yes  No
    If so, explain:
    11)  To your knowledge, has your child ever been exposed to the HIV virus? Yes  No
    12)  Does your child have a history of diabetes or hypoglycemia (low blood sugar)? Yes  No
    If so, explain:
    13)  Are there any other medical problems which you feel we should know about? Yes  No
    If so, explain:
    The above questions have been answered fully and to the best of my knowledge.
    Parent or guardian:

    Step 2

    Download the additional "Patient Instruction Sheet - Pediatric" form. Make sure to print and sign. Please make sure that you bring this form with you to your appointment.
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