CENTER FOR SPECIAL SURGERY

Pre-Registration Form

Your arrival time at the Surgery Center today: __________________________

Your scheduled procedure time today: ________________________________

SURGEON:_____________________________________________________

_____________________________________________________

(city, state, zip code)

Do you currently live in a nursing home? Yes_____ No _____

HOME PHONE: _______________WORK PHONE: _________________

CELL PHONE: _______________ FAX NUMBER: _________________

EMPLOYER: _______________

SEX: M _____ F _____ DATE OF BIRTH: ______________

SOCIAL SECURITY #:______________________________

Policy Holder (if not the patient): ___________________________________

Date of Birth: ___________________________________

IMPORTANT

We want to make sure that you understand every part of your care today. If you can read and

understand this message, please sign this registration form, hand it back to the receptionist, and

state your name.