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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?



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SHAWNEE MISSION HEALTH LOCATIONS
Shawnee Mission Medical Center
9100 West 74th Street
Shawnee Mission, Kansas 66204
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Main Number
913-676-2000
Prairie Star
23401 Prairie Star Parkway
Lenexa, Kansas 66227
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Main Number
913-676-8500