To submit this form, please ensure all sections are accurately completed. You can submit the form via the following methods: - Email: surgeryforms@childrensmercy.org - Fax: (816) 302-9928 - Mail: Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 - Online Submission: Visit our website and use the online form submission portal. For any questions or assistance, please contact us at (816) 855-1841. Our advice is to double-check all information and ensure signatures are included where required before submission.

There are no specific important dates for this form in 2024 and 2025. It should be completed and submitted prior to any scheduled surgery or procedure at Children's Mercy Kansas City.

The purpose of this form is to collect comprehensive patient information required for surgeries or procedures at Children's Mercy Kansas City. Accurate and complete documentation of the patient's medical history, current health status, and physical examination ensures the medical team has all necessary information to provide safe and effective care. This form aids in the pre-surgery assessment process and helps identify any potential risks or concerns that need to be addressed before proceeding with the procedure. By using this form, both patients and medical professionals can ensure a higher standard of preparation and safety for surgical and procedural outcomes.

• 1. Patient Information: Includes fields for first name, last name, gender, DOB, and other personal details.
• 2. Informant: Details about the individual providing information about the patient, including their first and last name, and relationship to the patient.
• 3. Chief Complaint: A brief description of the main issue or symptom that prompted the medical visit.
• 4. History of Present Illness (HPI): Detailed information about the current illness, including onset, duration, and associated symptoms.
• 5. Past Medical/Surgical History/Family History/Problem List: Includes the patient's past medical and surgical history, family medical history, and any known health issues.
• 6. Review of Systems: A comprehensive review of various body systems (e.g., HEENT, cardiovascular, gastrointestinal) to identify any symptoms not already mentioned.
• 7. Adverse Reactions: Records any known adverse reactions to medications or other substances.
• 8. Medications/Vitamins/Supplements: List of all medications, vitamins, and supplements the patient is currently taking.
• 9. Immunizations: Details about the patient's immunization status in accordance with ACIP guidelines.
• 10. Physical Exam: Findings from the physical examination, including vital signs and examination of various body systems.
• 11. Patient/Caregiver Consent: Confirmation that the patient or caregiver consents to the planned surgery or procedure.
• 12. Laboratory/Radiology/Ancillary Results: Any relevant laboratory, radiology, or ancillary test results that support the medical assessment.
• 13. Assessment/Plan: Summary of the medical assessment and proposed treatment plan, including the provider's signature and date.

Failure to submit this form can result in delays or cancellation of the scheduled surgery or procedure. It is crucial to ensure all required information is provided for a complete pre-surgery evaluation.

• Delay in Surgery: The surgery or procedure may be rescheduled if the form is not submitted on time.
• Incomplete Medical Assessment: Lack of necessary information can prevent the medical team from conducting a thorough pre-surgery evaluation.
• Increased Risk of Complications: Without comprehensive patient information, potential risks or concerns may not be identified and addressed.
• Cancellation of Procedure: In some cases, the surgery or procedure may be canceled due to insufficient information.
• Patient Inconvenience: Rescheduling or cancellation of the procedure can cause inconvenience and additional stress for the patient and their family.

• 1. Pre-Surgery Assessment: Used during the pre-surgery assessment to gather comprehensive patient information.
• 2. Medical Procedures: Required for documenting patient details before any medical procedure.
• 3. Consultations: Helpful during patient consultations to provide a thorough medical history.
• 4. Emergency Surgeries: Used in emergency situations to quickly gather essential patient information.
• 5. Post-Surgery Follow-Up: Can be referred to during post-surgery follow-ups to review patient history and treatment plans.