Patient Forms

Patient Forms

Each TCOM patient is required to fill out three forms, an initial Registration Form, a Patient Pre-Anesthesia and Surgery Questionnaire, and a Medication List.

Please click here to begin filling out the forms (these forms will be electronically emailed for you).

Please send these forms as soon as possible, and be sure to fill out all 3.

If convenient, you may download a PDF version of each form:

PDF Forms
Click on the forms below to print them out. PDF forms are not fillable online, rather they must be printed out and hand written. All three forms must be completed.

• Registration Form
• Patient Pre-Anesthesia / Surgery Questionnaire
• Medication List

After completing all three forms, please fax them to (309) 663-8972. Once TCOM receives your paperwork, we can register you and determine if you need pre-testing (for example, blood work, EKG, and /or an appointment with an anesthesiologist) prior to your surgery date.

For more information about surgery preparation, you can view the Patient Information Packet.