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503 874 0574

Falls Canyon Surgical Associates

Falls Canyon Surgical Associates

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    • Liska L. Havel, MD, MPH
    • James P. Nealon, MD, FACS
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    • Procedure Information
      • Appendectomy
      • Cholecystectomy
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    • Colonoscopy Preparation
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Patient Forms

๐Ÿ“ Patient Forms

To help us assist you prepare for your visit or assist you with your needs, please complete the relevant forms ahead of your appointment. You can download and print the forms below:

New Patients

All new patients to our clinic are required to fill out:

  • Patient Demographics Form
  • Health History Questionnaire
  • Medications and Allergies Form

Established Patients

Established patients that we have not seen in more than a year must fill out:

  • Page 2 of the Health History Questionnaire
  • Medications and Allergies Form

๐ŸŒ Patient Demographics Form

Patient Demographics Form (English)
Patient Demographics Form (Spanish)

๐Ÿฉบ Health History Questionnaire

Health History Questionnaire (English)
Health History Questionnaire (Spanish)

๐Ÿ“‚ Medication and Allergies Form

Medications and Allergies Form (English)
Medications and Allergies Form (Spanish)

๐Ÿงญ Hospital Campus Maps

Silverton Hospital Campus Map (English)
Silverton Hospital Campus Map (Spanish)
Stayton Hospital Campus Map (English)

If you have any questions about which forms to fill out, how to return them, or if your forms are missing from this list, please call our office at 503-874-0574. We’re happy to help!

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