Taylor Station Patient History Form
Please note: Taylor Station requires 2 Business Day notification for cancellations.
  • Taylor Station Patient History Form - 614-751-4466

    Please include as much information as possible.
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  • Please insert BMI from calculator ->
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  • Medication/Dose/Frequency/Reason for taking
  • Please rate your pain on a scale of 1-10 (0 being no pain and 10 being worst pain)
  • (0 being no pain and 10 being worst pain)
  • Ex. Post op nausea vomiting, Malignant hyperthermia, or been told you have a difficult airway.
  • Respiratory
  • NOTICE: Please bring CPAP machine and supplies with you to the surgery center.
  • Neurovascular / Muscular
  • Gastrointestinal
  • Cardiovascular
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  • Metabolic / Blood
  • Psycho-Social
  • Reproductive
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  • Instructions: Please read instructions for surgery or upper endoscopy and/or colonoscopy
  • Bring your insurance card and driver's license.

    If you have an advance directive please bring with you to the Center.

    Please wear your glasses but no contacts.

    Wear comfortable clothing, if you are having Breast or Shoulder surgery wear a button up shirt.

    DO NOT bring jewelry, money (except for your payment due day of procedure) or other valuables on the day of procedure, otherwise we will give it to your visitor to hold during your procedure.

    All metal or piercings on your body must be removed prior to surgery.

    Pre- procedure bathing/oral hygiene is essential for surgery. Once you bathe with soap do not put on any lotions, powders or hairsprays for head, neck, facial, upper back or upper extremity surgery.

    You MUST have an adult bring you and take you home from surgery.

    You MUST have someone stay with you that evening after surgery.

    No children under the age of 12 permitted in patient care area.

    Do not eat and drink according to the Center's directions once they call you, or your Physicians directions.

    Do not consume any mints, gum alcohol, or any tobacco products 12 hours prior to surgery.

    Follow your doctor's instructions, If you have any questions call the office.

    If you are having Orthopedic Surgery bring any assistive devices you have at home, otherwise we can provide and the company will bill you for the product.

    Taylor Station requires 2 Business Day notification for cancellations.
  • Taylor Station Surgical Center, LTD

    Transportation/Transfer and Responsible Adult Agreement

    Taylor Station Surgical Center, LTD (“Taylor Station”) requires each patient having
    a procedure involving anesthesia to be discharged in the company of a
    responsible adult and for this person to serve as my driver/caregiver to transport
    patients home after the procedure.

    I acknowledge that I have a responsible adult for purposes of discharge and that
    this person will serve as my driver/caregiver to transport me and stay with me
    after returning home from my procedure. I acknowledge that having such a
    person is required in order to have my procedure at Taylor Station. If no
    responsible adult is available at discharge for these purposes, I acknowledge that I
    will be transferred to the hospital to ensure my safety and Taylor Station will not
    be financially responsible for the cost of the transfer or hospital stay. I also
    understand public transportation such as a bus, Uber, Lyft or taxi is prohibited
    unless I am accompanied by my adult driver/caregiver.
    By signing below, in consideration for the procedure I have requested to be
    performed, I agree to accept the financial liabilities associated with any hospital
    stay in the event I do not have a responsible adult available at discharge and to
    transport me home at my time of discharge. To the fullest extent permitted by
    applicable law, I hereby release, forever discharge, and covenant not to sue Taylor
    Station, its affiliated companies, and their respective employees, members,
    officers, directors, managers, agents, and assigns, of and from all known or
    unknown claims or causes of action for liability, personal injury, death, pain and
    suffering, losses, lost wages, back pay, front pay, lost benefits, cost and expenses
    (including attorney's fees and costs actually incurred), and any other claims or
    damages of whatsoever kind or nature, either in law or in equity, arising from,
    connected with or in any way related to my failure to have a responsible adult
    driver/caregiver transport me home and stay with me following my discharge
    from Taylor Station.
  • *Note when submitting form - if you are NOT directed to a confirmation page after hitting the "Submit Form" button then please review the form for red highlighted errors and make necessary corrections.