Children's at Meridian Mark Surgical Services

If you have any questions, contact the presurgery phone nurse: 404-785-5615.

If you have trouble using our online form, download and print the form in English or Spanish. Fill out the form and then fax it to 404-785-5660.

*Please explain.
Enter date when symptoms first appeared.
*Describe the complaint
*Please describe
Date required.
Please give reason.
Surgeon's name is required.
Type of procedure required.
Please select.
Please explain.
*Please select
*Please explain
*Please explain

Important Information Needed on the Day of Your Child's Surgery: Please bring a list of the names and exact dosage of all medicine (including vitamins and herbal medicine) your child is currently taking with you on the day of surgery. This is very important so that we can prescribe the right medicine for your child after surgery.

*Please enter date
*Specialist name is required.
*Specialist phone number is required.
*Specialist name is required.
*Specialist phone number is required.
*Specialist name is required.
*Specialist phone number is required.
*Specialist name is required.
*Specialist phone number is required.
*Specialist name is required.
*Specialist phone number is required.
*Please specify how many weeks premature.
*Please specify birth weight.
Please describe problems.
*Specialist name is required.
*Specialist phone number is required.
Please explain.
*Specialist name is required.
*Specialist phone number is required.
*Date of last menstral period required (mm/dd/yyyy).
*Please select

If your child is 12 or older, or has started her menstrual cycle, we will need a urine specimen upon arrival to the surgery center.

*Specialist name is required.
*Specialist phone number is required.
*Specialist name is required.
*Specialist phone number is required.
*Chemotherapy type is required.
*Specialist name is required.
*Specialist phone number is required.
*Specialist name is required.
*Specialist phone number is required.
*Please explain
*Specialist name is required.
*Specialist phone number is required.
*Diagnosis is required.
*Specialist name is required.
*Specialist phone number is required.
*Please describe
*Please describe
*Please describe
*Please describe

*Please select
*Please describe

*What is your relationship to the child?
*DFAC Phone is required.
*Please specify what kind of transportation will be used.

You need to have arranged for transportation home prior to the day of surgery.

*Please select

(An Advance Directive is a legal way to make a decision about future medical care. A life threatening illness or injury can happen to anyone at any age. You can help control your care by recording your choices. The time to do this is before you are sick or injured). If your child already has an Advance Directive, please bring it with you on day of surgery. If you want more information, visit our Website and click on the link for Advance Directives. If you would like to speak with someone about Advance Directives, please call our Communication Nurse at 404-785-6712.

Patient and Parent Rights and Responsibilities

One day before surgery, you will be contacted with arrival time and specific eating and drinking instructions for the day of your child's procedure.

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