THIS FORM MUST BE FILLED OUT ON A DESKTOP OR LAPTOP. Due to security reasons it is not possible to complete it on a mobile device (phone, tablet, etc).
NOTE: You do not have to fill out a form again if you have already completed this online form prior to a previous visit. You may contact a nurse at (256) 772-6014 to discuss any updates to your medical information.
Please be forthcoming with your responses. All of your medical information is confidential.
You must complete the form in one sitting. You will not be able to save the information you have entered and return to complete the form at a later time.
The time it takes to complete the form is dependent on your personal medical history. Typically, a person who is healthy and not taking many medications should expect to spend 15 minutes completing the form. Someone with a more complicated medical history or list of medications will take longer.
NOTE:Microsoft Internet Explorer Version 11 is not supported and it may cause the application to misbehave. Madison Surgery Center recommends using Mozilla Firefox,as well as Google Chrome, Safari (partially supported), or Internet Explorer Versions 8 through Version 10.
Before you begin the online admissions form, please make sure that you have the following information available, as it may be needed to complete your form:
Prescription medications--names and dosage of each one you take.
Over-the-counter medication-- names and dosage of each one you take regularly.
Vitamin and herbal medications - names and dosage of any that you take.
Allergies/Sensitivities you have, and the allergic reaction(s) they cause.
Thank you for taking the time to complete this form. If you have already given this information to a nurse over the phone there is no need to complete this form. We appreciate you choosing Madison Surgery Center for your healthcare needs. Please answer all questions so we may have a thorough medical history for our anesthesiologist.
If you have any questions regarding your procedure please call (256) 772-6014 or email Preop@madisonsurgerycenter.com. Please try to complete this form no less than 3 days before your procedure/surgery.
Please provide your first and last name
If you don't know the time you are scheduled to arrive please call our office at (256) 319-9000 the day before your procedure to verify your arrival time.
Who will accompany you to the surgery center?
Please make certain they are available to remain in the facility for your entire visit. If your driver leaves the facility your procedure may be delayed or cancelled.
Please see question below if you check this box.
If you answered yes to breathing problems, throat swelling or anaphylactic please call (256) 319-9000 and ask to speak to a nurse. You may not be a candidate for a procedure at Madison Surgery Center.
Please list any allergies to medications, food, tape, etc.INCLUDING your reaction.
Do you have any
****If you have a pacemaker or defibrillator please call the center at (256) 319-9000 and ask to speak to a nurse regarding this device before your date of procedure.****
If you have a Defibrillator you are not a candidate for a procedure at Madison Surgery Center. Please call the number above to make sure we can get you rescheduled through your Dr's office.
please note any heart surgeries, catheterizations or stent placements in the box below including dates.
please note when your last seizure occured in the box provided below.
please note the date of your stroke or TIA and any problems you may have as a result of that incident in the box provided below. examples are weakness on one side, difficulty with speech, memory problems, etc.
Do you have any metal or prosthesis in your body?
Have you ever had a blood transfusion?
Advance Directive / Living Will
Do you have an Advance Directive or Living Will?
If so you may bring a copy with you to add to your chart.
Please check what applies do you
Medications, supplements, herbals
Please list your current medications, supplements, herbals, etc. and dosages one per line (for example: Aspirin 81mg daily) or simply "None".
You may copy and paste into this text box but you cannot 'attach' a list.
DO NOT ASSUME THAT YOUR PHYSICIAN HAS PROVIDED A MEDICATION LIST FOR OUR RECORDS. This information is for your Anesthesiologist and must be completed.
Please check with your physician if you did not receive instructions about your medications the morning of your procedure. You may need to take some of them with just enough water to swallow them. If you cannot reach your Dr's office, you may call (256) 772-6014 for general information.
List previous surgeries one per line *dates are not necessary unless you have had a recent cardiac surgery*(if you have had no surgeries simply write "None")
List any previous problems with anesthesia. This includes problems had by anyone in your family, i.e Malignant Hyperthermia, pseudocholinesterase deficiency, etc.
I am aware to NOT eat,drink, use tobacco, chew gum, mints or candy of any kind for 8 hrs before my procedure.
(If you are having a colonoscopy please follow your instructions from your Dr's office. Your procedure may be delayed or cancelled if you do not follow these instructions)
I am aware I am to bring my insurance card(s) and driver's license along with a form of payment for my copay/deductible if I have one.
Please leave all other valuables at home.
I have read and understand the PreOp Instructions located on the Madison Surgery Center website. Please bring your insurance card and a picture ID with you on your date of service.
If you have any questions regarding these instructions please call (256) 772-6014.
IF PATIENT IS A CHILD...
Any relation other than birth parent will require legal documentation for Madison Surgery Center to legally treat this child. Please bring any documents with you on the morning of the procedure. If you have any questions regarding which paperwork is needed please call (256) 319-9000 as soon as possible.
If you have traveled outside the US in the last 4-6 weeks? Or if you have been in contact with anyone who has?
Pressing 'Submit' will transmit your information to our system. Please make sure you have completed the form in it's entirety as you will not be able to access it to edit it. If the form is not completed the system will direct you to the missing information for you to complete. There is no need to call to verify receipt of the form.