Please list the people with whom we can discuss your care and leave messages.
The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for Minimally Invasive Surgical Associates to share my protected health information with:
Please let us know of all the doctors you see.
Please check all symptoms you currently experience, or have experienced in the past year:
Office Use: STOP BANG Score (3-4 = Intermediate Risk, > 5 = High Risk):