Welcome to Colorado Surgical Service

We look forward to meeting you on the day of your appointment.

Please Download and Print:
(if you need assistance downloading and printing refer to the instructions a the bottom of this letter, otherwise click to download)
1. Patient Registration Form
2. Medical History Questionnaire

It is very important each space be completed. If you have "no information" to provide for a certain space, please indicate with either a line or N/A (not applicable).

Under "Primary Insurance" be sure to give the subscriber name (person who carries the insurance) and subscriber number (typically the insured's social security number). In addition, please list the group number, address and telephone number of the insurance company.

If you have no Secondary Insurance, please indicate by writing "none", however, if you do please complete information as previously stated.

If your visit is a follow-up on an auto accident, please provide the responsible party's name, insurance company, address, phone, policy number, claim number and date of accident.

For worker's compensation, please provide the worker's compensation carrier (insurance company), claim number and date of injury.

It is very important to complete the enclosed forms. If you have had any recent testing pertaining to the problem you will be seeing our doctor for, please bring the written report with you at the time of your appointment.

If you are a member of an insurance that requires a referral from your primary care physician, please see to it that this is obtained prior to your visit. We will need your insurance card(s), driver's license or some other type of picture identification, along with your completed forms at the time of your appointment.

Payment is expected at the time of your visit unless previous arrangements have been made. All co-pays are due at time of service.

If you have any questions, please call our office.

INSTRUCTIONS FOR PRINTING FORMS:

Please print BOTH of the following forms prior to your visit to Colorado Surgical Service. These Forms are in Adobe Acrobat PDF format and you will need Adobe Acrobat Reader Software to read and print them. If you do not have Acrobat Reader, please download the free Reader software first by clicking the Adobe Acrobat Website link. A new browser window will open that website. If you have any trouble, please email our office.

Form #1: Patient Registration Form

Form #2: Medical History Questionnaire

Form #3: Dr. Asad's Breast Form

Introductory Letter (same text as above)