Patient Checklist (All patients must complete the following, prior to surgery)
_____ Please let the practice/office know a few weeks in advance the date you would like your surgery.
Below you may print our package for new patients. These forms are required to open a chart for you.
_____Please complete the forms & bring to your initial visit or send the documents electronically prior to your visit. (The consent forms will be signed in our office after your consultation with Dr. Perito.)
Pre-Op Tests & Clearance
_____Please provide a medical clearance from your internist. Pre-op testing required includes:
CBC, PT, PTT, BMP, URINE ANALYSIS, CHEST X-RAY, EKG AND MEDICAL CLEARANCE LETTER
If you are unable to obtain medical clearance please contact our office to discuss pre-operative requirements.
If you have any history of cardiac issues, we also request a cardiac clearance.
Insurance & self-pay information
_____ If you have insurance, please forward the following:
- Full Name on Policy
- Date of Birth
- Member #
- Group #
- Telephone # for Insurer
_____ * If possible, scan & attach a copy of your ID/Insurance card.
* If you do not have insurance, please contact us directly for the cost of your procedure @ (305) 444-2920
For more amenities surrounding your care you may also visit the “concierge care” section at peritourology.com
Please contact our office directly with any further questions or email your request through the “contact” section
at peritourology.com. Thank you for helping to expedite your visit by completing the paperwork in advance.
To print this page click here