Preoperative Forms

Pay Your Surgery Center of Silverdale, LLC Bill Online: 

Patient name & MRN/acct #

Surgery Center of Silverdale

9800 Levin Road, Suite 102
Silverdale, WA 98383
Map & Directions

Phone 360.692.2728
Fax 360.692.6009

New Patient Registration

Print Patient Satisfaction Survey

Preoperative Forms & Information

These forms contain important and useful information you will need as a patient at the Surgery Center of Silverdale. You should carefully review all the information, fill out all the included forms and sign in all areas where a patient signature is indicated. If your surgery is more than a week away, mail the forms in the provided envelope (with the physical packet). If your surgery is less than a week away, bring the completed information to the Center on the day of your procedure. Be sure to bring a copy of your insurance card as well.

Patient Information Pamphlet

Patient info pamphlet_revised 0613.pdf (720.7KB)


Receipt of Patient Information

Receipt of Patient Information_rev 050611.pdf (32.4KB)

Registration Form

Complete both sides of this form and mail it in or bring it with you on the day of the procedure.

View Registration Form

Allergy & Medication List

Fill this out completely and sign at the bottom.  Be sure to include all medications you are taking along with the dosage.

View Allergy & Medication List

Notice of Privacy Practices:

Read this to better understand how the Center will protect the privacy of your health information.

View Notice of Privacy Practices

Authorization for Disclosure of Health Information:

Fill this out to let us know who is allowed to have access to information about your health, such as friends or family members who might call to check on your status during surgery.   If you do not complete this form, we won't share your information with anyone.

View Authorization for Disclosure of Health Information


If you have any questions, our Patient Account Representatives will be glad to answer them. 

Call us at (360) 692-2728 between the hours of 7am and 5pm, Monday through Friday.