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This questionnaire will help your surgical team at MRSC determine what, if any, preoperative work up will be needed prior to your surgery and help them gather all available medical information about you.

Step 1: Print the form and fill it out as best as you can.
This information will help to avoid any delay in your surgery.

Step 2: Please send the completed and signed form to

Our Anesthesiology Department will review your answers and determine if further testing or action needs to be taken prior to your scheduled surgery.

In some cases, we will contact you to schedule an appointment for a preoperative Anesthesia evaluation at our center.

If you have any questions, please call Manhattan Reproductive Surgery Center at 212-818-0001.

Take Your Reproductive Health into Your Own Hands