1.  If you have been told by a doctor that you have an abnormal pap smear / or have been suffering from chronic pelvic pain for more than six months, then you may qualify for our same day treatment option.
2. Obtain a copy of abnormal pap smear if possible
3. Review instructions and fill out information form before calling our office.
4. Call office with information ready to make an appointment.
5. Once travel arrangements have been made, call for airport pick-up and accommodation information.
6. Arrive at our office at least 15" before scheduled time in morning (local hotel pick-up available)
7. NOTHING to eat or drink after midnight the night before appointment.

Information Form:

Information you will need when you call our office.
(or e-mail this form or print out this form and fax it to
912-871-2510 and we will call you):

  Name  
  Date of Birth  
  Address  
  Daytime Telephone Number  
  EMail Address  
  Problem   Abnormal Pap Smear
Chronic Pelvic Pain
Pain With Sex
Painful Periods

  Insurance Company  
  Insurance Policy Number  
  Effective Date  
 

Abnormal Pap Smear Results:
Patients must bring a copy of results

 
  Past Medical History:
Please list problems with the heart, lungs, blood, stomach, kidneys, bladder, bones and joints, or nervous system.
 
 

Any Previous Treatment for Abnormal Pap: colposcopy with biopsy, endocervical curretage (ECC), cone biopsy, or LEEP

 
 
  Any Chronic Medical Disease?   None
Heart Disease
Lung Disease
Kidney Disease
Problems with Anesthesia
Diabetes
Bleeding Problems
 

Medications:
Please list all medications you are taking and current doses. Also list any over the counter medicines and herbals or supplements.

 
  Allergies:
Please list allergies to antibiotics, medications, latex
 
  Any Previous Surgery  
  Any Previous Anesthesia Complications?  
     

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