Ambulatory Surgery Center Pre-Operative Intake Form

Streamline Pre-Operative Patient Assessment with Paperform

Managing pre-operative intake at an ambulatory surgery center requires careful attention to detail, regulatory compliance, and clear communication between patients, surgical teams, and anesthesia providers. Our Ambulatory Surgery Center Pre-Operative Intake Form template gives healthcare administrators, surgical coordinators, and clinical staff a comprehensive digital solution for collecting critical patient information before same-day surgical procedures.

Why Digital Pre-Op Forms Matter for Ambulatory Surgery Centers

Traditional paper-based pre-operative assessments create bottlenecks, increase the risk of incomplete information, and make it difficult to flag potential complications before the day of surgery. With Paperform's ambulatory surgery intake template, your facility can:

• Reduce day-of-surgery cancellations by identifying NPO non-compliance, medication conflicts, or anesthesia concerns in advance
• Improve patient safety through structured collection of anesthesia history, allergies, and current medications
• Streamline workflows by automatically routing completed forms to surgical coordinators, anesthesiologists, and nursing staff
• Ensure regulatory compliance with proper documentation of informed consent discussions and discharge planning
• Save clinical staff time by having patients complete detailed health histories before arrival

Built for Healthcare Professionals and Surgical Coordinators

This template is specifically designed for ambulatory surgery centers, outpatient surgical facilities, and hospital-based same-day surgery programs. Whether you're a surgical coordinator, pre-operative nurse, anesthesia provider, or healthcare administrator, this form captures everything needed for safe, efficient outpatient surgery:

• Comprehensive medical and surgical history
• Detailed anesthesia experience and complications
• Current medication list with verification of holds and adjustments
• NPO (nothing by mouth) compliance confirmation
• COVID-19 screening and infectious disease protocols
• Responsible adult transportation and 24-hour caregiver verification
• Advance directive and emergency contact information
• Insurance and authorization documentation

Key Features for Surgical Excellence

Conditional Logic for Clinical Pathways: The form uses smart branching to ask follow-up questions only when relevant—if a patient indicates previous anesthesia complications, additional detail fields appear automatically. This keeps the form streamlined while capturing comprehensive information when needed.

Same-Day Discharge Planning: Built-in sections verify that patients have arranged appropriate post-operative care, including transportation home and a responsible adult to stay with them for 24 hours, reducing discharge delays and improving patient safety.

Medication Management: Clear sections for patients to list current medications, recent changes, and confirmation of pre-operative medication instructions (such as holding blood thinners or diabetes medications) help prevent adverse events.

Mobile-Friendly Patient Experience: Patients can complete the form on any device before their surgery date, reducing waiting room time and allowing clinical staff to review information in advance and contact patients if clarifications are needed.

Automate Pre-Op Workflows with Stepper

Connect your Paperform pre-operative intake to Stepper, Paperform's AI-native workflow builder, to create seamless clinical processes:

• Automatically send completed forms to the surgical coordinator, anesthesiologist, and pre-op nursing team
• Flag high-risk patients (multiple anesthesia complications, complex medical history) for early anesthesia consultation
• Trigger reminder emails about NPO instructions, medication holds, and what to bring on surgery day
• Create tasks for pre-op phone calls when additional information is needed
• Update your surgery scheduling system or EMR with patient-reported information
• Send post-submission confirmation with personalized pre-operative instructions

Collect eSignatures for Consent Documentation

While this intake form gathers essential health information, you can seamlessly connect it to Papersign for collecting required consent signatures. After patients complete their pre-operative assessment, automatically generate and send surgical consent forms, anesthesia consent forms, or facility-specific acknowledgments for eSignature, creating a complete digital record linked to the original intake submission.

Designed for Healthcare Security and Compliance

While Paperform is not HIPAA compliant and should not be used for protected health information requiring HIPAA safeguards, it offers robust security features suitable for many healthcare administrative workflows. For facilities using Paperform for pre-registration and preliminary intake, the platform provides SOC 2 Type II compliance, SSL encryption, and secure data handling.

For HIPAA-compliant patient data collection, consult with your compliance team about appropriate solutions for your specific clinical environment.

Who Benefits from This Template

Ambulatory Surgery Centers can reduce pre-operative workload, decrease day-of-surgery cancellations, and improve patient flow by collecting comprehensive health information in advance.

Surgical Coordinators gain visibility into patient readiness, can identify potential issues early, and spend less time on phone calls gathering missing information.

Anesthesia Providers receive detailed anesthesia histories, medication lists, and risk factors before the day of surgery, allowing for better preparation and reduced complications.

Pre-Operative Nurses can focus their pre-op assessment time on physical examination and patient education rather than data entry, improving efficiency and patient experience.

Hospital Outpatient Departments can standardize pre-operative assessment across different surgical specialties while maintaining flexibility for specialty-specific questions.

Customization for Your Facility's Protocols

Every surgical facility has unique pre-operative protocols, required documentation, and clinical pathways. Paperform's intuitive editor makes it simple to customize this template:

• Add facility-specific pre-operative instructions or educational content
• Include fields for procedure-specific requirements (bowel prep for colonoscopy, pregnancy testing for certain procedures)
• Customize NPO instructions based on your anesthesia department's protocols
• Add insurance authorization or verification questions
• Include COVID-19 or other infectious disease screening questions that match your current policies
• Adjust language and formatting to match your facility's brand and patient communication style

Get Started Today

This ambulatory surgery center pre-operative intake template gives healthcare teams a professional, comprehensive tool for collecting critical patient information before same-day surgical procedures. With Paperform's healthcare-friendly features, conditional logic, and workflow automation through Stepper, you can create a seamless pre-operative experience that improves patient safety, reduces cancellations, and saves valuable clinical time.

Start with this template and customize it to match your facility's exact protocols and requirements. Whether you're managing a single-specialty ASC or a multi-specialty outpatient surgical facility, Paperform provides the flexibility and functionality you need to deliver excellent surgical care.