Patient Forms


Patient Forms

The free Adobe Acrobat Reader is required to access and print our forms. If you do not have it, get it for free here.

If you are looking for our new records review registration form, please scroll down.


Please click here to access our policies regarding the following:

CEC Cancellation/No Show Policy for Office Appointments
CEC Cancellation/No Show Policy for Surgery
CEC Pain Management Policy

CEC Notice of Privacy Practices
CEC Travel Policy for our International & Out-Of-Town Surgical Patients
CEC Policy on Social Media Interaction
CEC Policy Regarding Administrative Fees


if you are: a first-time PATIENT with an in-office appointment date ALREADY SCHEDULED and YOU have been asked to download the 'new appointment' forms, Click here

if you are: a registered, prospective NEW patient undergoing the free review & PHONE CONSULT (UNREGISTERED RECORDS WILL NOT BE REVIEWED) and have been asked to download the 'free review' forms, click here

if you are: a post-operative patient and have been asked to download the 'CEC evaluation' form, click here

if you are: a post-surgical patient and have been asked to download the 'follow-up questionnaire' at least 6 months after the date of your surgery, click here

if you are: seeking a medical records release form to provide your doctor's office with in order to have them send us your records (sending of separate records must be approved by program director first), click here

if you are: a prior cec patient in need of additional copies of your records from us (two operative sets are provided TO YOU at POST-OP AT no cost) for another provider (charges will apply, see office policies above), click here

if you are: seeking a copy of our bowel prep instruction sheet (also provided at preop), click here

If you are: seeking a copy of our prohibited pre-surgical medication list (also provided in pre-surgical packet), click here

if you are: seeking a copy of our hipAa policy (see also our privacy policy above), click here

Si usted está: buscando una copia de nuestro documento de póliza de seguro en español, haga clic aquí





The following form is for new records review cases only. Please do not register if you are an existing CEC patient (current or any year prior) or have (or plan to schedule) an in-office appointment. If you are an existing CEC patient (from any year) in need of assistance, please call us at 770-913-0001 and we'll be delighted to help you. If you were looking to book an in-office appointment (consult costs apply), please note appointments are not made online. Call us at 770-913-0001 and our staff will be delighted to book you and review the costs/insurance aspects with you. Thank you. We also strongly encourage our visitors to read our FAQs as well when considering the CEC for their care.

Every registration is responded to by email (or postal mail if email is not available) with an information packet and necessary requirements for the free records review, usually within 24-48 hours. If you do not receive your packet, please check your spam file. If you receive an email from one of our surgeons but not your packet of instructions, that means the mail went to your blocked/spam file. Please check and notify us accordingly. Please understand that regrettably, we cannot process case reviews on an 'urgent' basis. Before proceeding, please also be sure to read our guidelines regarding high BMI and other surgical risk factors which may influence our ability to consider your surgical candidacy.

PLEASE REMEMBER TO INPUT YOUR FULL MAILING ADDRESS. Incomplete registrations will not enable us to start your file.

We are glad you're here and look forward to hopefully being able to help!

Date of Birth *
Date of Birth
Phone Number *
Phone Number