Medical Information Form | YVSC

top of page

Physician
Our Mission
Quick Costs
Insurance
Procedures
Contact
More

Use tab to navigate through the menu items.

MEDICAL INFORMATION

To facilitate your visit, please provide the following information:

First Name

Last Name

List any surgeries you have had

List medical conditions for which you are currently under treatment (high blood pressure, diabetes, heart disease, asthma, etc.)

List any allergies you have to medications and the reaction (for example, penicillin—rash)

Please indicate if you use tobacco, alcohol, or recreational drugs * Required

Alcohol

Tobacco

Recreational Drugs

None

Please indicate your understanding of why you are having this procedure

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

You're almost done. Just fill out the List of Medication Form. and you'll be finished.

© 2025 by Yamhill Valley Surgical Center

bottom of page