SURGI CENTER APPOINTMENT FORM

SURGI CENTER APPOINTMENT FORM

SURGI CENTER APPOINTMENT FORM
  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 50.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
    This is the date the history and physical should be received by. Failing to do so will result in the cancellation of the appointment at the surgicenter.
  • LINK FOR H/P PAPER WORK https://littleteethprinceton.edentalforms.com/hp-caphealth-surgicenter/
  • FAX H/P TO 732-862-3498
    • I HEREBY ACKNOWLEDGE THAT THE ABOVE DATE HAS BEEN RESERVED FOR MY CHILD AT THE CAPITAL HEALTH SURGI CENTER.
    • IF THE APPOINTMENT IS CANCELLED WITHIN 24 HRS OF THE APPOINTMENT WITHOUT A VALID REASON AND PROOF,  WE WILL NOT GUARANTEE ANOTHER APPOINTMENT WITH THE SURGICENTER.
    • I AGREE TO SEND THE H/P FORM BY THE DUE DATE MENTIONED ABOVE. FAILING TO DO SO WILL RESULT IN THE AUTOMATIC CANCELLATION OF THE APPOINTMENT BY THE CAPITAL HEALTH SURGI-CENTER.
  • BY SIGNING I UNDERSTAND THE ABOVE MENTIONED AND AGREE TO ABIDE BY THE POLICY OF THE SURGICENTER.