Pre-Surgical | Patient Registration

Personalized Care ♟ Pre-Surgical Testing

Let's get to know you...in private.
Name*

First NameLast Name
DOB

MonthDayYear
Date
Sex assigned at birth

MaleFemale
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address: Please list the location you would like a service at. *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment
I'm here because I need pre-surgical clearance for my upcoming procedure:*

YesNoOther
What is the date of your surgery?*

MonthDayYear
Date
Please provide the name of your surgeon:*
What type of surgery are you having?*
Please specify the type of surgery you are scheduled for:
Have you had any recent illnesses or infections in the last 2 weeks?

YesNo
If you answered yes, please specify:
Please select all needed pre-surgical or post-surgical related care needed:*

Lab Work/Blood TestsCovid Test and/or Full Respiratory Viral PanelChest X-RayMRI or CT ScanUltrasound TestEKG (3-lead, 12-lead)An at-home physical assessment/examination from a medical providerPost-Op CareI'm not sure and need help figuring out what's needed.Other
Medical History

We care about you...
Height *
Feet & Inches
Weight*
Lbs
Do you have any allergies?*

YesNo
Please list your allergies:
Are you taking any medications?*

YesNo
Please list your Current Medications:
Have you ever had surgery before?*

YesNo
Please list Surgical Procedures & Dates of Each:
Have you ever had a reaction to anesthesia?

YesNoI'm unsure and need further clarificationI have never had anesthesia before.
If yes, please describe the reaction and the type of anesthesia used (if known):
Have you ever had (Please check all that apply)

NoneAnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaOther
Please specify Other Illnesses:
Healthy & Unhealthy Habits

No judgements, offering improvements upon request...
Exercise

Never1-2 days3-4 days5+ days
Eating habits/following a diet

I have a loose dietI have a strict dietI eat generally healthy, but I could make improvementsI don't have a diet plan
Alcohol Consumption

I don't drinkI am a social drinker (less than 5 drinks/week)1-2 glasses/day3-4 glasses/day5+ glasses/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Do you Vape?

YesNo
Are there any other elements or substances in your routine?

NoneCaffeineMarijuanaMagic MushroomsCocaineMDMA and/or 2CBLSDMethamphetamineOther
Please upload any orders or forms from your medical doctor or surgeon (if applicable):

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Some insurance policies cover the components necessary for pre-surgical clearance. Upload the front and back of your insurance card here:

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We want to put a face to your name :) Please upload the front and back of your government-issued ID here:

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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION TO THIRD PARTY PURSUANT TO HIPAA

This authorization indicates a disclosure of information pertaining to medical records and the release of official laboratory results/treatment to a third party for the intended medical reasons. I, the patient, allow Checkmate Health to release any/all results and reports from my pre-surgical testing to my medical doctor, surgeon, and/or the affiliates involved in my healthcare and surgical planning.

I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form to only those agreed upon for the my surgical care.
CHECKMATE HEALTH AUTHORIZATION TO GIVE MEDICAL CARE – CONSENT TO TREATMENT: I hereby voluntarily consent to treatment and care from all medical personnel contracted with Checkmate Health. I further consent to the performance of any diagnostic procedures, examinations, laboratory tests and rendering of medical treatment by Checkmate Healths' medical Providers and staff, as is necessary in the medical staff’s judgment. I understand that this consent will be valid and remain in effect as long as I am a patient at the clinic. *

Clear
Date

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Date
Submission Date

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Date
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Hour Minutes

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Personalized Care ♟ Pre-Surgical Testing

Medical History

Healthy & Unhealthy Habits