FORMS & INSTRUCTIONS
FORMS
Medical Forms
If you are a new patient or have not been to our practice within the last six months, please bring Driver’s License or other photo identification, updated Insurance card(s), required insurance co-payment and (if your insurance requires) referral to your appointment. If your insurance coverage changes during the course of treatment, please notify the office immediately. Failure to provide accurate insurance information can and will delay recommended medical treatments.
If you are scheduled for Breast surgery consultation, please make sure you obtain & bring copies of anyrelevant X-rays and reports to the appointment. Thank you.
PATIENT FORMS
(Please print, complete and bring to your appointment)
- Benrus Surgical Office Rules and Expectations
- Multi Providers New Patient Form, except Dr. Jerad Miller
- Dr. Jerad Miller New Patient Form
- Workers Compensation Patient Information form
- Medical Records Request: Obtain/Release Records
- All Surgeon Patient Forms (except Dr. Miller)
- Medical Records Release to Benrus
- Medical Records Release to other Facility
PROCEDURE PREPARATION AND AFTERCARE INSTRUCTIONS
- Rubberband Ligation aftercare instructions
- Conservative Treatment for Hemorrhoids
- Hemorrhoidectomy surgery aftercare instructions
- Laparoscopic Gallbladder aftercare instructions
- Anal Pruritus (anal itching)
- Anal Fissure
- Sitz Bath
- Pilonidal Cyst Excision aftercare instructions
- High Fiber Diet
- Laparoscopic Nissen Fundoplication Surgery Diet Guidelines
- Gallbladder suppression diet
- In Office Excision and Biopsy aftercare Instructions
- Surgical Excision in the Operating Room aftercare Instructions
- Porta Cath (port) Placement
- How to care for a Urinary Catheter
- Instruction for 2 fleet enema’s
- Instruction for clear liquids ONLY
- Miralax Prep
- SuPrep Colonoscopy Prep
- GoLytely Prep
- SuTab Colonoscopy Prep
- Day 2 clear liquid after Colonoscopy-Surgery next day instructions
- After Mastectomy w/ drain log
- After Partial Mastectomy w/ drain log
- Drain Care
- Blank Drain log
- Wound Care after Incision and Drainage
- Precautions following removal of Lymph Nodes
- Partial Mastectomy/Sentinel Lymph Node Biopsy Aftercare
- Laparoscopic Nissen Fundoplication Surgery Diet Guidelines
- Medication and Surgery-Before your Operation
- Hernia surgery aftercare instructions