Patient Forms

For your protection ―we ask that you DO NOT email us information concerning billing or health issues. Please direct your inquiries and concerns during your visit at the center. Have you read our FAQs page?

Please complete these forms prior to the day of surgery:

  • History and Physical. Please check with your surgeon to find out if he will be completing this form or whether your general practitioner will need to complete it.

  • Health Survey. This form is to be completed by you and will provide the anesthesiologist and our clinical staff with information that will assist them as they plan your care.

  • Medication Reconciliation. This form is to be completed by you. It gives us information on your current medications and helps us to avoid medication errors as omissions, duplications, drug interactions and dosing errors.

Failure to complete these forms in advance of the day of surgery may result in your procedure being delayed or postponed. You can bring these forms with you on the day of surgery, fax them to the center at 302-777-2111, OR mail them to:

ATTN TO: Front Office
900 Foulk Rd, Suite 100
Wilmington, DE 19803

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When you choose our physicians at the American Surgery Center, you are choosing the highest quality patient care from Delaware's top surgeons.


Patient Information


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