Heritage Surgical Associates

New Patient Intake Form

📋 Important: Please complete this form at least 48 hours before your scheduled appointment. All fields marked with * are required.

Contact Information

Full Name *

Email Address *

Phone Number *

Preferred Location

Preferred Surgeon

Surgery/Appointment Date

Appointment Time

Chief Complaint & Medical History

What is your main issue or concern? *

Days since symptoms started

Pain Level (1-10): 5

Does this interfere with: (check all that apply)

WalkingClimbing stairsDrivingWork

How long have you had these symptoms?

What treatments have you already tried?

Previous Imaging

Imaging Results (if known)

Have you had previous surgery on this area?

YesNo

If yes, please describe previous surgeries

Pre-Operative & Day-Of Information

Preferred arrival time (if applicable)

IV/Prep concerns or preferences

Anesthesia questions or concerns

Post-operative information interests

Verification

By submitting this form, I certify that the information provided is accurate to the best of my knowledge. I understand that this form does not establish a patient-provider relationship and that I will need to schedule an appointment for evaluation.

[reCAPTCHA verification placeholder - would appear here in production]