Patient Pre-Op Form

Surgery Forms

At East Valley Outpatient Surgery, we try to avoid patients having to spend time filling out forms in our waiting room right before surgery. We ask you to please fill out the form below at home and bring it with you. If you are unsure what to include, please fill out as much as you can, and our staff will be happy to assist when you come to the facility.

In addition, a patient representative will call you before surgery to review crucial medical history and insurance information. When you arrive at EVOS, you will be asked to check the printout for accuracy and makes any changes.

Click the link below to view and download the form (pdf):

Patient Records

Your medical information is automatically transferred from your physician at East Valley Ophthalmology to East Valley Outpatient Surgery via Electronic Medical Records (EMR).

Patients' Rights

Click the link below to view and download (pdf):

Surgery Forms

easy patient formsSave Time on Surgery Day!
Please fill out these Pre-Op Patient Forms and bring them with you.

EMR Transfer

EMR Electronic Medical Records

Information from your doctor at East Valley Ophthalmology is
automatically transferred to East Valley Outpatient Surgery.

Children & Visitors

Only the person who will be driving you to and from your appointment will be allowed inside East Valley Outpatient Surgery with you. In order to reduce the possible spread of disease, additional visitors are not allowed in our surgical facility. This person must remain present while your surgery is being done. Please make appropriate arrangements for child care outside of our office. We appreciate your understanding.

Personal Items

Please bring a government-issued photo ID, insurance information, and a list of all current medications, dosage amounts, and time of day you take them. Wear comfortable clothing. Do NOT wear any makeup or nail polish. Leave all jewelry and valuables at home.

Driver Required

All patients must arrange for a responsible adult driver (over the age of 18) to remain in the surgery center during the entire stay. Your driver must have a valid driver's license. Failure to have a driver could result in a delay or the cancellation of your procedure. Taxi, Uber, bus, and other forms of public transportation are acceptable only if you have a responsible adult companion with you.

Prohibited Items

Please leave food, drink, and cell phones outside of our facility. No form of tobacco use is permitted on any part of the East Valley Outpatient Surgery property. This includes buildings, sidewalks, and parking areas on or near the property. We appreciate your understanding.

Insurance

Please check with your insurance provider to ensure you're eligible for benefits. When applicable, we're happy to work with you on a case-by case-basis to provide you with all documentation needed for maximum insurance reimbursement. If insurance does not cover the procedure, the patient is ultimately responsible for all charges.

Recording Devices

Consistent with state and federal privacy laws, and as a condition of treatment, audio, photographic, or video recordings are not permitted inside East Valley Outpatient Surgery. Should anyone be observed recording or taking photographs with a cellphone or other device, the individual will be asked to immediately erase the audio, video, or photographs to protect the privacy of persons present.