Surgical History
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
David Street, M.D.
William Faught, M.D.
David Traul M.D.
Mark Eaton M.D.
Juan Castillo M.D.
Nancy O'Neal M.D.
Mitchell Plummer M.D.
Patrick Phelan M.D.
Jeffery Herbert PA-C
Stephani Cook PA-C
Pamela Reeger Cortell FNP
Kelsey Young PA-C
Natalie Baxter PA-C
Alexandra Lanzi PA-C
Brittany Lanzi PA-C
Lena Varner FNP
My provider is not in the list
---------- Date of Birth ----------
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Male
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Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Please mark all surgeries you have had
I have had no surgeries
Head or Neck
Brain
Cataract
Deviated Nose Septum
Sinus
Tonsillectomy
Parathyroid
Thyroid
Breast
Biopsy
Mastectomy
Lymph Nodes
Cancer Lump Removal
Breast Reduction
Breast Enlargement
Chest
Esophagus
Lung
Abdomen
Gallbladder
Anti-Reflux
Stomach
Bariatric
Hernia
Spleen
Appendectomy
Small Bowel
Bowel Obstruction
Colon Removal
Anal/Rectal
Anal Fissure
Peri-Rectal Abscess
Hemorrhoidectomy
Gynecological
Caesarean Section
Tubal Ligation
Ovary Removal
Hysterectomy (due to cancer)
Hysterectomy (not due to cancer)
Urological
Kidney
Prostate
Vasectomy
Bladder
Ureteral Stent
Vascular/Heart
Abdominal Aortic Aneurysm
Carotid Artery
Iliac Artery
Renal Artery
Peripheral Vascular
Leg Veins
Heart Bypass
Heart Valve Replacement
Musculoskeletal
Neck Disc
Back
Joint Replacement
Other
Skin/Lymph Nodes
Skin Ulcer
Abscess Drainage
Skin Cancer Removal
Plastic Surgery
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 607
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.