same-day surgery request form condition/ surgery type requested - Select -CircumcisionInguinal herniaLip tieTongue tieUmbilical herniaUndescended testicle patient information patient's first name patient's last name gender - Select -FemaleMale patient's date of birth patient's weight patient's height What insurance do you have for your child? (i.e. United Healthcare, Caresource, etc.) Does your child have a complicated medical history (poorly controlled asthma, seizures, cardiac history, insulin dependent diabetes, respiratory illness requiring supplemental oxygen, bleeding disorders, moderate to severe sleep apneaetc.)? - Select -YesNo Does your child have a personal history or family history of malignant hyperthermia? - Select -YesNo Do any of the following conditions or syndromes apply to your child? Please check all boxes that apply. Muscular dystrophyProgressive weaknessIn need of muscle biopsyDystrophic epidermolysis bullosaWilliams SyndromeHunter SyndromeHurler SyndromeSickle cell anemiaOther progressive neurological or muscular diseaseNone of the above Was your child born prematurely? - Select -YesNo contact information parent/guardian's first name parent/guardian's last name phone number street address state zip code email
