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.
  1. Pre-anesthesia Surgery Questionnaire
  2. HIPAA Notice of Privacy Practices
  3. CMS Notification Requirememts
  4. Patient Rights
  5. Patient Intake Form
  6. Patient’s Current Medications
  7. Preparing for Your Procedure
  8. Patient Survey

You may complete the following forms online if you choose

  1. Pre-anesthesia Surgery Questionnaire
  2. CMS Notification Requirememts
  3. Patient Intake Form
  4. Patient’s Current Medications
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.
© 2013 Roxbury Surgery Center. No reproductions or other use of these plans may be made without the express written consent of Roxbury Surgery Center.