NEW PATIENT FORMS
Please complete the following forms and mail them to our office or bring them with you to your appointment.
- Complete the Patient Information Form to provide your demographic and insurance information to Surgical Institute.
- Complete the Patient Health History Form to provide your health history to Surgical Institute.
- Complete and sign the Acknowledgement of Receipt of Privacy Notice to affirm that you have received a copy of our Privacy Notice and to authorize us to speak to family or friends on your behalf.
- Review Surgical Institute's Privacy Notice. You may print a copy for your records if you wish.
- Driving Directions to Surgical Institute (includes parking and hotel information)
WEIGHT LOSS PATIENT FORMS
Weight loss patients must complete an online Patient Information Form after attending a seminar. The form must be completed at least 1 week prior to your consultation with the doctor. Please contact our office if you need help accessing or completing your Patient Information Form.
MEDICAL RECORD RELEASE AUTHORIZATION FORMS
If you'd like a copy of your medical records sent to another facility, please complete and return a signed authorization form to our office:
Attention: Medical Records
Surgical Institute of South Dakota
911 E. 20th St. #700
Sioux Falls, SD 57105
(605) 334-6028 Fax
Use this form to authorize your physician to release your medical records to Surgical Institute.
Use this form to authorize Surgical Institute to release your medical records to another physician, or for any other purpose.