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Shawnee Mission Surgery Center

Surgery Pre-Registration

General Information

Patient Information

Emergency Contacts

Name of responsible adult with you day of surgery (if having anesthesia)
Is it OK to share any medical information and/or home instructions with this person?

Medical Information

Did you receive the Patient Bill of Rights brochure from your surgeon’s office?
List any surgeries/major illnesses (including cancer) you have had and approximate date
Have you or a blood relative ever had a complication/reaction from anesthesia?
(fever, malignant hyperthermia, difficulty awakening, nausea, airway complications)
List any ALLERGIES to medications, iodine/contrast dye, latex, tape or food. Include reaction.
List the medications you are currently taking, the dose and time of day you take them.
Check if you have ever had any of the following:

Are there any religious or cultural beliefs that would affect your care?
Are you in an abusive situation or do you lack support?

Women Only

* Required
Shawnee Mission Medical Center
9100 West 74th Street
Shawnee Mission, Kansas 66204
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Prairie Star
23401 Prairie Star Parkway
Lenexa, Kansas 66227
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