It's a simple process…

Please be forthcoming with your responses. All of your medical information is confidential.

  • The time it takes to complete the form is dependent on your personal medical history. Someone with a more complicated medical history or list of medications will take longer. The average time to complete is 25-30 minutes.
  • Upon receipt of your information, a staff member or nurse may call you for further clarification if necessary.

NOTE –  You do not have to fill out a form again if you have had surgery at Mayfield Spine Surgery Center within the last 6 months and have already completed this online form prior to your previous surgery. A nurse will call you to discuss your medical history once complete



What will I need?

Before you begin the online admissions form, please make sure that you have the following information available, as it may be needed to complete your form:

****EVEN IF YOU ARE AN ESTABLISHED PATIENT WITH MAYFIELD BRAIN AND SPINE OR MAYFIELD SPINE SURGERY CENTER YOU MUST LIST ALL MEDICATIONS THAT YOU TAKE AND ARE PRESCRIBED.  THIS LIST SHOULD ALSO INCLUDE ANY MEDICATIONS YOU MAY HAVE ALREADY STOPPED IN PREPARATION FOR YOUR UPCOMING SURGERY*******


  • Prescription medications – names and dosage of each one you take.
  • Over-the-counter medication – names and dosage of each one you take regularly.
  • Vitamin and herbal medications - names and dosage of any that you take.
  • Allergies/Sensitivities you have, and the allergic reaction(s) they cause.
  • Previous surgeries, and the year they were performed.
  • Medical Insurance – insurance company, policy number, ID number, etc.



New Patient

For new patients, or if you wish to start a new form, please enter the password that was provided to you by your medical facility:
Enter Password Here:


Returning Patients

If you'd like to resume, modify, or review an existing form please enter the secured access token provided by the Surgery Center and your date of birth.