Things to Bring to your Pre-Op Consultation

There are a few things that you can do in order to make your pre-operation office visit go smoothly. Please be aware that no surgery is performed at the initial consultation visit, but the child must be physically present.

  • A parent or legal guardian must accompany the child to the consultation appointment:

    - If you are a legal guardian we will need to see the legal papers that indicate your legal guardian status

    - If you are the parent but do not have legal custody, we will need to see the legal papers that allow you to make health care decisions for your child

    - In the event a legal guardian cannot accompany the child to the appointment, the person with the child at the appointment must bring a legally executed power of attorney form to the appointment (to be legally executed, the form must be signed by a legal guardian and notarized)
  • Your insurance card, photo identification, insurance authorization and medical records.
  • Your child's insurance card, social security number, and photo identification (if possible).
  • Applicable co-payment is due at time of check-in.
  • If your insurance requires authorization it is your responsibility to have that forwarded to our office as soon as possible. Our fax number is 727-767-4346. 
  • Parents/guardians are responsible for ensuring that the referring physician's records and applicable tests (x-rays, etc.) are sent prior or present with the child at the time of the appointment.
  • Bring a list of prescription and non-prescription medication and vitamin supplements the child is taking, including the name dose and instructions.

Please note that failure to have appropriate authorization will result in either rescheduling the appointment or treating patient as a self-pay, and payment must be made at time of service.

Also note that failure to have relevant medical records and x-rays may result in rescheduling of the appointment.

Forms

Please complete these forms and bring them with you to your first appointment. If you received forms before your visit, please bring those completed forms with you to the appointment as well.

 Name  Description Download   
Patient Registration Form Basic patient information needed to add patients into the system. (English) (en Espanol
Patient History A description of the medical history of the patient.  (English) (en Espanol
Ambulatory Care Consent Form Granting permission to provide routine diagnostic procedures and treatment. (English) (en Espanol

Additionally, you may be asked to complete these forms:

 Name  Description Download   
Consent to Operation A form that gives the surgeons permission to treat the patient.  (English) (en Espanol
Authorization to Release information for Continuity of Care This form permits our office to share the patient's information with other healthcare providers.  (English) (en Espanol)

 

Billing Policy

  • Insurance deductible and co-payment are due at time of check-in
  • Surgery co-payments are due two days prior to the surgery
  • Elective surgeries may be rescheduled in the event of non-payment
  • Please remember if your insurance requires authorization it is your responsibility to have that forwarded to our office as soon as possible. Our fax number is 727-767-4346
  • Failure to have appropriate authorization will result in either rescheduling the appointment or treating patient as a self-pay and payment must be made at time of service.

Appointments and More Information

For more information, visit Pediatric General Surgery. To make an appointment or to ask questions, please call (727) -767-4170.