Siouxland Surgery

Pre-Registration

Pre-Registration

Pre-RegistrationPre-registration is required at the Siouxland Surgery Center. You may contact our office to register, either in person or by telephone, between the hours of 9 a.m. and 5 p.m., Monday through Friday. Our telephone number is (605) 232-3332.

You may also fill out our pre-registration form online for your convenience.

When you call to register, please be prepared to supply the following information:

• Insured’s Social Security Number
• Insurance Company
• Policy Number
• Group Number
• Address and Telephone Number
• Employer

req = Required Field

Online Pre-Registration Form

Contact Information:

req Email Address:

req First Name:

req Last Name:

req Street Address:

req City, State, Zip:

Home Phone Number: (111-111-1111)

Work Phone Number: (111-111-1111)

 

Health History:

Personal Information:

Gender:

Date of Birth:

Height:
Feet:  Inches:
 

Allergies / Reactions:

 

YES

NO

Medication Allergies:

Food Allergies:

Latex Allergies:

Other Allergies:

List All Allergies:

  

Patient Health History:

Does the Patient Have or Ever Had:

YES

NO

A. Heart Problems (Congestive Heart Failure, Chest Pain, Murmur,
     Irregular Heart Beat, Heart Attack, Rheumatic Fever, Ankle Swelling, Etc.)

B. High or Low Blood Pressure

C. Lung Problems (Asthma, Emphysema, COPD, Tuberculosis)

D. Neurologic Problems (Seizure, Stroke)

E. Diabetes

F. Hypoglycemia (Low Blood Sugar)

G. Kidney Problems

H. Thyroid Problems

I. Liver Problems (Hepatitis, Jaundice)

J. Acid Reflux/ Esophageal Disease

K. Bleeding Problems or take blood thinners

L. Problems with Anesthesia (You or any member of your family)

M. Smoking / Tobacco Use

N. Do you wear contact lenses?
     

O. Do you have any special communication needs? - If YES, please specify

    

1. Vision

YES

NO

  

 

2. Hearing

YES

NO

  

 

3. Language

YES

NO

  

 

4. Speech

YES

NO

  

 

P. Do you have any physical limitations?

    If YES, please specify

YES

NO

  

 

Q. Do you take any medications?
     List all meds including aspirin, or Advil / Motrin / Ibuprofen, other over-the-counter meds.

    If YES, please list

YES

NO

  

 

R. Do you take any vitamins, herbal or "alternative" medications?

    If YES, please list

YES

NO

  

 

S. Have you ever had surgery before? Please list past surgeries.

    If YES, please list

YES

NO