• Preoperative Assessment Consent Form

    Complete this form before your scheduled procedure to provide your medical history, medications, allergies, and consent-related acknowledgments needed for the preoperative assessment.

  • Patient Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Procedure and Scheduling Details

  • Scheduled Date and Time*

  • Medical History and Risk Screening

  • Current Diagnoses or Conditions
  • Prior Surgeries
  • Any Previous Anesthesia Complications or Reactions?*
  • History of Bleeding or Clotting Problems?*
  • Heart or Lung Disease?*
  • Diabetes, Hypertension, or Sleep Apnea?*

  • Medications, Allergies, and Special Considerations

  • Other allergies
  • Tobacco, alcohol, or substance use
  • Pregnancy or breastfeeding status
  • Mobility, communication, or special assistance needs

  • Preoperative Instructions and Consent

  • Do you understand and agree to follow the fasting and medication instructions provided?*
  • Do you understand that you may need a responsible adult to accompany you home after the procedure?*
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