Patient Forms

Patient Forms

Each patient of TCOM is responsible for filling out the following forms:

Online Forms

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

Please send these forms as soon as possible. If convenient, you may download a PDF version of each form:

PDF Forms

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

and 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.