Patient Forms
Completing your forms before you arrive makes check-in faster on the day of your procedure.
Our patient forms are being finalized ahead of our October 2026 opening. Call (510) 513-5747 or email info@rivasurgerycenter.com and we will send you the forms you need.
Forms you will receive
Patient Registration
Your contact information, emergency contact, and insurance details. Required for every patient.
Coming soon
Health History Questionnaire
Your medical and surgical history, current medications, and allergies. Please complete this fully — our nursing team uses it to prepare for your care.
Coming soon
Consent for Treatment and Anesthesia
Reviewed and signed at the facility. Consent for your specific procedure is handled by your surgeon’s office.
Coming soon
Financial Responsibility Agreement
Explains your payment responsibility and assignment of insurance benefits.
Coming soon
Authorization for Release of Medical Information
Needed if you want your records sent to another provider.
Coming soon
Notice of Privacy Practices
Explains how we use and protect your medical information, and your rights over your record. You will be asked to acknowledge that you received it.
Coming soon
Patient Rights and Responsibilities
Your rights as a patient at RIVA Surgery Center, provided to you in advance of your procedure.
Coming soon
Advance Directive Information
Our policy on advance directives, provided in advance of your procedure. If you have an advance directive or POLST form, please bring a copy.
Coming soon
Physician Ownership Disclosure
A written disclosure that physicians who perform procedures here hold a financial interest in the facility. You are free to choose another provider.
Coming soon
Good Faith Estimate
An estimate of your costs, available if you are uninsured or not using insurance for your procedure.
Coming soon
Bringing your forms
- Complete every section — blank fields slow down check-in
- Bring the completed forms with you, along with your photo ID and insurance card
- If you need help completing them, call us and we will walk through them with you
- If you need forms in Spanish or in large print, tell us and we will provide them
Si necesita los formularios en español, llámenos al (510) 513-5747.
Need forms sent to you?
Call (510) 513-5747 or email info@rivasurgerycenter.com and tell us which forms you need.
Please do not email medical information. Email is not a secure channel. Send us only your name and what you need; bring the completed forms with you or mail them.