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Patient Forms


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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.

CEC POLICIES

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

CEC FORMS

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

if you are: a registered prospective new patient undergoing the free review (do not send forms or records unless you have been registered and received your e-packet) 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 'post-op 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 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

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REGISTRATION


REGISTRATION


PLEASE READ CAREFULLY BEFORE PROCEEDING TO YOUR REGISTRATION INPUT:

The following registration form is for new records review and evaluation 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 hoursIf you do not receive your packet, please check your spam file. Please take care to input your email address correctly, double-checking that you have given us accurate information. 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.

Please remember to fill out ALL AREAS OF REQUESTED INFORMATION (*=required), particularly full address details. You may enter 'n/a' where appropriate. Again, please remember this form is not for patients who have undergone treatment with us previously (from any year). Please do not register if you have been a CEC patient before; please contact us at 770-913-0001 and we will be delighted to help you with any concerns. 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