Please complete this ENTIRE form and bring it with you to your scheduled appointment.  This is used to up date your medical history and reduce the risks of complications from surgery and anesthesia.

Thank you for your assistance.

PLEASE BRING ANY IMMUNIZATION DATES FOR TETANUS, PNEUMOVAX OR RECENT FLU SHOTS IF YOU HAVE THESE RECORDS. 

PREOPERATIVE CLEARANCE MAY REQUIRE:  LABS, XRAYS OR EKGs.  WE WILL ALSO DO OUR BEST TO UPDATE ALL RECOMMENDED HEALTH MAINTENANCE ITEMS AT THE TIME OF THIS VISIT OR, IF TIME IS LIMITED, WE WILL SCHEDULE THESE BEFORE YOU LEAVE.