Please enable JavaScript in your browser to complete this form.Surgeon *Please SelectAlp OzpinarAnderson, CharlesBascom, ThomasBock, KimberlyBrackebusch, JoyceBrian WakefieldBryan WilliamsCatherine YorkChristensen, NathanClark, KatelynCusati, DanielDeHaas, DavidDiego MuilenburgFrank ChenFreeman, JenniferGarrett, AudreyGerhards, SaraHaugen, JulieHenderson, WinnieHerrmann, DavidHutton, DanielIngalls, NicholeJewett, PaulaKelel, KristyKokkino, AndrewKollmorgen, ChristineKosek, PeterKyle, BrookeMcCourt, MichaelModeste, KevinMovassaghi, KiumarsRoundy, NeilSeidman, CraigStenshoel, TamaraTucker, ToddTufariello, JenniferWong, JeffYang, EdmundYang, KathleenDate of SurgeryName *Date of Birth *Address *Sex *MFOtherCity/State/Zip *Social Security *Phone * HWCReferring Physician *Phone *HWCPrimary Physician *Email *Emergency Contacts (Please provide 2)Contact Name *Contact Name *Relationship *Relationship *Phone *Phone *Employment InformationEmployedUnemployedRetiredOtherOccupationEmployer AddressExplanation (if other)City/State/ZipEmployerPhoneGuarantorSame as patientNameGuarantor EmployerDate of BirthSocial Security #PhoneAddressAddressCity/State/ZipCity/State/Zip Primary InsuranceInsured Name *Relationship to Insured *Social Security *Insurance Company Name *Date of Birth *Insurance ID# *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSecondary InsuranceInsured Name Relationship to InsuredSocial Security Insurance Company NameDate of BirthInsurance ID#Address Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDemographic InformationPlease note that this survey is a requirement by The State of Oregon Department of Health for Ambulatory Surgery Centers and is being performed in accordance with the State of Oregon Department of Health. These questions are strictly confidential and will only be used for state reporting purposes. Please check the answer that applies to you. EthnicityWhite/EuropeanBlack/AfricanHispanic/LatinoNative AmericanOtherRaceWhiteBlack/African AmericanIndian/Alaskan NativeAsian Bi-racialNative American/Pacific IslanderOtherReligionChristianJewishMuslimHinduBuddhistNoneOtherCommentSubmit
