Pre-Operative Health History

Please complete all sections as accurately as possible. This information is required before your anesthesia appointment.

Important: A G2 Anesthesia representative will contact you to personally review your medical history at least 14 days before your appointment if medically necessary. If you have questions, call (502) 503-4755.

Patient's Full Name*

Date of Birth*

Age*

Gender*

MaleFemaleOther

Height

Weight (lbs)

Surgeon / Dentist Name*

Date of Surgery / Procedure*

Street Address

State

Zip Code

Home / Cell Phone*

Emergency Contact Name & Phone*

Email Address*

Your information is transmitted securely and used only for your anesthesia care. Questions? Call (502) 503-4755