Children's at Scottish Rite Surgical Services

Pre-anesthesia History Form

If you have any questions, contact the presurgery phone nurse: 404-785-4664


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* Required Fields

* Child's Legal First Name:    
* Child's Legal Last Name:  
  Nickname:  
  Surgeon:
  Pediatrician Name:  
  Pediatrician Phone:  
  Today's Date:  
* Date of Birth: (mm/dd/yyyy)
  Age:  
  Sex:  
Height must be written in feet and inches.
* Height: (feet) (inches)
* Weight: (pounds)
* BMI (Body Mass Index):
* Date of Surgery: (mm/dd/yyyy)
* Operation: