Surgery Forms

Local Pre-Op Questionnaire


This form will take approximately 10-15 minutes to complete. It is not complete until you hit send and receive a confirmation email. 

Contact Information
List Your Allergies & Reactions


*Stop Coumadin and Herbal Supplements 5 days prior to the procedure.
Stop Aspirin and Plavix 7 days prior to the procedure.

IMPORTANT: If your physician is with Saunders Medical Center Family Care Clinic we will obtain this list for you. If not, note your medications below.

Anesthesia Background | Check All That Apply
Current Health Information
I have and use: (Check all that apply)

Your Health History
Heart Health
Please check all that apply to you and note comments below on each section.
Other Health History