Surgery Center at Tanasbourne
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Patient Registration Form
The fields marked with * are required
Patient Name:
*
First:
Middle Initial:
*
Last:
*
Date Of Birth:
(MM/DD/YYYY)
*
Address:
City / State / Zip:
*
City:
*
State:
Choose A State...
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*
Zip:
*
Best Phone Number
To Be Reached At:
XXX-XXX-XXXX
Best Time To Call:
Morning
Afternoon
Evening
Alternate Phone Number:
XXX-XXX-XXXX
Email Address:
Marital Status:
Single
Married
Divorced
Widowed
Separated
Cohabitating
Primary Care Physician:
Employer Name:
Employment Status:
Full Time
Part Time
On-Call
Unemployed
NOTE:
The State of Oregon requires us to ask the following two questions. Answers are not required.
Do you consider yourself
Hispanic/Latino?:
Yes
No
Decline to Answer
Which category best
describes your race?:
Please Select One
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White or Caucasian
Multiracial
Unavailable / Unknown
Decline to Answer
Doctor:
Benz Brooke M.D.
Buuck David M.D.
Carter Christopher M.D.
Cavanaugh Megan M.D.
Cober Sheldon M.D.
Cook David M.D.
Corbin Christine M.D.
De La Melena Tammy M.D.
Dehqanzada Yama M.D.
Frankhouse Joseph M.D.
Gabel Steven M.D.
Gentile Michael D.P.M
Gilster Jason M.D.
Grunkemeier David M.D.
Heinonen Larry M.D.
Irish Edwin M.D.
Johnson Jeffrey M.D.
Kaplan Paul M.D.
Kaynard Alan M.D.
Keating Angela M.D.
Kim Shane M.D.
Klotz Michael M.D.
Koval George M.D.
Lobitz John M.D.
Norling Mark M.D.
Owens Michael M.D.
Payne Susan M.D.
Penikas Jeffery M.D.
Phinney Edward M.D.
Reindl Elizabeth M.D.
Rosales Camilo M.D.
Ruff Ronald M.D.
Shumaker Doug M.D.
Sleven Rodger M.D.
Stapleton Joseph M.D.
Strauss Mitchell M.D.
Surratt Jason D.P.M
Teed Ronald M.D.
Thum Lisa M.D.
Vallejos Cristian M.D.
Vu Kim-Chi M.D.
Weprin Jeff M.D.
Williams Diane M.D.
Other
Insert "Other" here:
Scheduled Procedure:
Scheduled Date of Service:
(MM/DD/YYYY)
Scheduled Procedure:
Height / Weight:
Height:
1'
2'
3'
4'
5'
6'
7'
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight:
lbs.
Contacts / Dentures:
Contacts?
Yes
No
Dentures?
Yes
No
Braces / Loose Teeth:
Braces?
Yes
No
Loose Teeth?
Yes
No
Neurological:
You:
Stroke
Epilepsy
Seizures
Fainting
Migraines
Speech Deficit
Dizziness
Other:
Blood Relatives:
Stroke
Epilepsy
Seizures
Fainting
Migraines
Speech Deficit
Dizziness
Other:
Eyes, Ears, Nose & Throat:
You:
Sinus Problems
Ear Infection
Glaucoma
Hard Of Hearing
Blindness
Right
Left
Both
Other:
Blood Relatives:
Sinus Problems
Ear Infection
Glaucoma
Hard Of Hearing
Blindness
Right
Left
Both
Other:
Cardiovascular:
You:
Angina
Heart Attack
Congestive Heart Failure
Rapid Or Irregular Heart Beat
Pacemaker
Rheumatic Fever
Peripheral Vascular Disease
Other:
Blood Relatives:
Angina
Heart Attack
Congestive Heart Failure
Rapid Or Irregular Heart Beat
Pacemaker
Rheumatic Fever
Peripheral Vascular Disease
Other:
Respiratory:
You:
Bronchitis
Asthma
Pneumonia
COPD
Sleep Apnea
Other:
Blood Relatives:
Bronchitis
Asthma
Pneumonia
COPD
Sleep Apnea
Other:
GI/GU:
You:
Peptic Ulcer
Hiatal Hernia
Liver
Ostomy
Nausea
GERD
Dialysis
Kidney/Bladder Infection
Other:
Blood Relatives:
Peptic Ulcer
Hiatal Hernia
Liver
Ostomy
Nausea
GERD
Dialysis
Kidney/Bladder Infection
Other:
Endocrine:
You:
Diabetes
Thyroid
Other:
Blood Relatives:
Diabetes
Thyroid
Other:
Skin:
You:
Rash
Ulcers
Wounds
Other:
Blood Relatives:
Rash
Ulcers
Wounds
Other:
Musculoskeletal:
You:
Arthritis
Osteoporosis
Fracture
Back Pain
Other:
Blood Relatives:
Arthritis
Osteoporosis
Fracture
Back Pain
Other:
Blood:
You:
Bleeding/Clotting Problems
Tranfusion Reactions
Sickle Cell
Other:
Blood Relatives:
Bleeding/Clotting Problems
Tranfusion Reactions
Sickle Cell
Other:
Infectious Diseases:
You:
Hepatitis
TB
AIDS
HIV
MRSA
VRE
STD
Other:
Blood Relatives:
Hepatitis
TB
AIDS
HIV
MRSA
VRE
STD
Other:
Communicable Diseases:
You:
Measles
Chicken Pox
Mumps
Rubella
Recent Exposure
Other:
Blood Relatives:
Measles
Chicken Pox
Mumps
Rubella
Recent Exposure
Other:
Mental Health:
You:
Emotional Problems
Depression
Bipolar Disorder
Other:
Blood Relatives:
Emotional Problems
Depression
Bipolar Disorder
Other:
Anesthesia:
You:
Problems With Anesthesia
Malignant Hyperthermia
Other:
Blood Relatives:
Problems With Anesthesia
Malignant Hyperthermia
Other:
Menstrual period:
Are You Currently Menstrating?
Yes
No
N/A
Date of Last Monthly Period
(MM/DD/YYYY)
Allergies:
Previous Surgeries:
Please list all previous surgeries:
Surgery
Date
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
Did you have pain after surgery?
Yes
No
N/A
What pain meds worked for you?
Driver / Caretaker:
Who will you be bringing with you?
Relationship to you:
Discharge Plan:
*
Who will be driving you home?
*
Phone number of person driving you home:
XXX-XXX-XXXX
*
Rights & Responsibilities:
I have read and understand the
Patient Rights & Responsibilities
:
You must check "Yes" for form to be submitted
Yes
No
Note: Minor children need to know the legal guardian and bring legal paperwork to the surgery center day of surgery. All minor patients require a parent to stay in the facility during surgery.