Pre-Procedure Forms and Instructions

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Pre-Procedure Forms and Instructions

This packet contains important information relating to your surgery or procedure. Please download, complete and sign the enclosed forms prior to arriving at the center. Forms must be completed in ink and brought with you on the date of service.


You will need Adobe Acrobat Reader (which is available for free) in order to view these files. You can download and install Acrobat Reader from this link: http://www.adobe.com/products/acrobat/readstep2.html


  1. Patient Identification/Site Verification Checklist
  2. Patient’s Home Medications
  3. Pre-anesthesia Surgery Questionnaire
  4. HIPAA Notice of Privacy Practices
  5. Race/Ethnicity Form (required by the State of California)
  6. CMS Notification Requirememts
  7. Patient Rights and Responsibilities

Please read the SAMPLE consent forms below. DO NOT complete them. You will be required to sign actual consent forms when you arrive.


Please read the following form regarding Payment and Billing Information.
We are happy to serve you and strive to provide our patients the best possible care.
We hope your experience is a positive one.


 
Phone: (949) 631-0988  •  Fax: (949) 631-2504
361 Hospital Road, Suite 124   •  Newport Beach, CA 92663
e-mail: contacts@nbsc.cc