Preparing For Your Surgery

* denotes a required field

Please pre-register no less than 24-hours prior to your appointment.

If you have questions about pre-registration, contact us at 913-632-9328, Monday - Friday, 8:00 a.m. - 4:30 p.m.

Patient Information:

Location:

Shawnee Mission Surgery Center (main campus)
Prairie Star Surgery Center (Shawnee Mission Outpatient Pavilion)

Last Name: *

Maiden / Previous Legal Name:

First Name: *

Middle Name:

Is this your first time at SMMC?

Date of Birth: *

/ / (ex. 12/31/2006)

Social Security Number: *

- -

Sex: *

Marital Status: *

Spouse's Name:

Spouse's Sex: *

Race: *

Religion:

Address: *

City: *

State: *

Zip Code: *

Home Phone: *

- -

Cell Phone:

- -

Email:

Appointment Information:

Primary Care Physician/Family Doctor: *

Ordering Doctor/Surgeon:

Appointment Date: *

/ / (ex. 12/31/2006)

Appointment Time:

Do you currently see a heart doctor?

Physician Name(s):

Your appointment is related to: *

Comments:

Emergency Contacts:

Name and phone number of person who will be with you on the day of surgery:

Primary Contact Relationship: *

Primary Contact: *

Address: *

City: *

State: *

Zip Code: *

Primary Contact Phone: *

- -

Primary Contact Alternative Phone:

- -

Secondary Contact Relationship:

Secondary Contact:

Secondary Contact Phone:

- -

Insurance Information:

Insured or Self-Pay? *

Relationship to Patient: *

Subscriber Name: *

Subscriber DOB: *

/ / (ex. 12/31/2006)

Subscriber SSN: *

- -

Employer:
Employer Phone:	- -

Is Primary Insurance Medicare? *

Primary Insurance Company: *

Primary Insurance Address: *

Primary Insurance City: *

Primary Insurance State: *

Primary Insurance Zip Code: *

Primary Insurance Company Phone: *

- -

Primary Policy Number: *

Primary Group Name:

Primary Group Number:

Primary Insurance Plan Type: *

Do you have Secondary Insurance? *

Relationship to Patient: *

Subscriber Name: *

Subscriber DOB: *

/ / (ex. 12/31/2006)

Subscriber SSN: *

- -

Employer:
Employer Phone:	- -

Secondary Insurance Company: *

Secondary Insurance Address: *

Secondary Insurance City: *

Secondary Insurance State: *

Secondary Insurance Zip Code: *

Secondary Insurance Company Phone: *

- -

Secondary Policy Number: *

Secondary Group Name:

Secondary Group Number:

Secondary Insurance Plan Type: *

Medicare Secondary Payer Questionnaire:

Are you receiving Black Lung (BL) Benefits? *

Are the services to be paid by a government program such as a research grant? *

Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for care at this facility? *

Was the illness/injury due to a work related accident/condition? *

Date benefits begin: *	/ / (ex. 12/31/2006)
Name & Address of WC Plan: (1)
Policy or ID Number: (1)
Name & Address of Your Employer: (1)
Name & Address of WC Plan: (2)
Policy or ID Number: (2)
Name & Address of Your Employer: (2)

Was the illness/injury due to a non-work related accident? *

Was another party responsible for this accident? *

Are you entitled to Medicare based on? *

Are you currently employed? *

Name and address of your employer:

Is your spouse currently employed? *

Name and address of your spouse's employer:

Do you have group health plan (GHP) coverage based on your own, or your spouse's current employment: *

Does your employer that sponsors your GHP employ 20 or more employees? *

Are you currently employed? *

Name and address of your employer:

Is your spouse currently employed? *

Name and address of your spouse's employer:

Do you have group health plan (GHP) coverage based on your own, or your spouse's current employment: *

Does your employer that sponsors your GHP employ 20 or more employees? *

Do you have Group Health Plan (GHP) Coverage? *

Have you ever received a kidney transplant? *

Have you ever received maintenance dialysis treatments? *

Are you within the 30-month coordination period? *

Are you entitled to Medicare on the basis of either ESRD and age or ESRD and disability? *

Does the working aged or disability MSP provision apply? *

Anesthesia:

Type of Anesthesia:

Current Height:

Current Weight:

List the Medications you are currently taking, the dose and time of day you take them: (Include prescription, over-the-counter meds, herbal, topical, inhalers, eye drops, vitamins and diet aids):

List any ALLERGIES to medications, iodine/contrast dye, latex, tape or food. Include reaction:

List any surgeries/major illness (including cancer) you have had, and approximate date:

Have you or a blood relative ever had a complication/reaction from anesthesia? (fever, difficulty awakening, nausea, airway complications)

Have you been hospitalized at Shawnee Mission Medical Center within the last year?

Do you have Advance Directives?

Check if you have or have ever had any of the following:

Neuro/Pain
Stroke Depression Alzheimers Migraines Numbness/tingling	TIA Panic Attacks Dementia Weakness Multiple Sclerosis	Parkinsons Anxiety Confusion Seizures Myasthenia Gravis

Currently having any pain (acute or chronic)? Where?

Circulatory
Chest Pain/Angina High Blood Pressure Pacemaker/Defibrillator Poor Circulation Bl. Transfusion Reaction Blood Disorders	MI/Heart Attack Heart Murmur Cardiac Cath Bleeding/Anemia History of Blood Clots	Heart Failure Irregular Heartbeat Angioplasty/Stent Blood Disorder Sickle Cell

When and where was your last ECG (heart tracing)?

Respiratory
Shortness of Breath Sleep Apnea (C-PAP, Bi-PAP) Recent Cold/Bronchitis	Emphysema/COPD Recent Pneumonia Use of Oxygen	Asthma with inhaler Asthma without inhaler Jaw Joint Problems Seasonal Allergies

Do you smoke?

Yes, I smoke
Packs/Day:
# of years:
Quit:

GI/GU
Recent UTI Kidney Disease Heartburn/Acid Reflux Diverticulosis/Diverticulitis Irritable Bowel Cirrhosis Lost 10+ lbs. the last month	Prostate Disorders Dialysis Ulcer Ulcerative Colitis Diarrhea C-Diff within last year	Kidney Stones Hiatal Hernia GI Bleed Crohns Jaundice Alcohol/Drug Use
Muscular/Skeletal
Arthritis History of Fractures	Degenerative Joint Disease Use cane/walker/wheelchair	Fibromyalgia Chronic Fatique
Skin/Infection
Tuberculosis Current rash, abrasion, lacerations MRSA/VRE (antibiotic resistant)	Hepatitis A Hepatitis B Hepatitis C	Hepatitis D Hepatitis E
Endocrine/Reproductive
Diabetes Type I or II	Use Insulin	Thyroid Disease

Women Only

1st day of last menstrual period:
Currently pregnant?
Menopause?

Children

Normal Birth Hx
Normal Development
Immunizations Current

You must click "Submit" on the next page to for us to receive your Pre-Registration!

SMMC is a tobacco-free campus. Click here for more information.

CONTACT US

Surgical Services

GI Services: 913-676-2534
Prairie Star Surgery Center: 913-676-8550
Surgical Services (Main OR): 913-632-2200
Shawnee Mission Surgery Center: 913-632-9333

RELATED RESOURCES

Other services of interest

MY ACCOUNT INSURANCE WE ACCEPT

Log in to your account

Click the button below to pre-register or log-in to your account

Check here to find out if we accept your insurance plan. Select your provider from the list

Or search our database If you are unable to find your plan listed, please contact Patient Financial Services at 913-676-2238. This is not a guarantee of benefits. Member must be eligible at the time of service. Refer to your Certificate or Summary Plan Description for all your plan details, including what's covered as well as limitations and exclusions. In the event that your insurance does not pay, please contact Patient Financial Services at 913-676-2238 for payment options.