Preoperative Cystoscopy Intake Form
Please complete this form to provide essential information for your upcoming cystoscopy procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Reason for Cystoscopy
*
Hematuria (blood in urine)
Recurrent urinary tract infections
Bladder pain or discomfort
Follow-up for previous bladder condition
Other
Do you have any known allergies?
*
No known allergies
Yes, to medications
Yes, to latex
Yes, to other substances
Other
Are you currently taking any medications?
*
No
Yes (please list below)
Have you had any previous surgeries or procedures related to your urinary tract or bladder?
*
No
Yes (please specify below)
Preferred Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit Form
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