Surgery Center: Dr. K. Robert Williams

Dr. K. Robert Williams Surgery Center Request

Package pricing applies only to self-pay procedures performed in-office or at the Premier Surgery Center.
Full name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
E-mail*
example@example.com
Birthday*

MonthDayYear
What type of surgery are you interested in? *Note: if you are interested in Bariatric Surgery, you will be redirected to the New Patient Paperwork for New Life Center for Bariatic Surgery. Please print/complete the forms and bring them with you to your first appointment. *
Your weight?*
Your height?*
Have you ever had a reaction to anesthesia?*

YesNo
Do you have a history of any of these conditions?*

AsthmaDiabetesHeart AttackHigh Blood PressureHigh CholesterolStrokeOtherNone
Primary Care Physician
Primary Care Physician's Phone Number
Do you have health insurance?*

YesNo
Additional information or comments:
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Dr. K. Robert Williams Surgery Center Request