Your surgeon has referred you for outpatient surgery at Belmont / Harlem Surgery Center. We must know your medical history prior to your procedure.

The Online Pre-Operative Medical Assessment must be completed As Soon As Possible BEFORE your surgery. You will need the following information to complete the form.


  • List of all medications

  • List of allergies and sensitivities

  • Name and date of previous surgeries

  • Your medical history

Completing the secure Online Medical Assessment is easy, and all of your information is kept confidential.

  • Complete all sections.

  • If a section does not apply select the check box for “No Issues".

  • Be sure to include a complete medical history: including conditions you currently have, take medication for, or conditions you had in the past.

User tip: If completing this survey on your smart phone, rotate your device sideways (landscape) for larger text.

Upon receipt at Belmont / Harlem Surgery, someone from our team will call you regarding your surgery. Please see our Patient Guide to Surgery section with preparation for surgery instructions.


Medicare Users can use Medicare's Procedure Price Look up tool to compare the national average price for procedures done in ambulatory surgical centers.  Medicare allows you to search by procedure name or code.

Healthcare Bluebook is a well known online tool to compare out of pocket medical expenses including what a surgery center procedure might costs.

Belmont / Harlem Surgery Center accepts CareCredit®. Care credit is for patients who may need financial help, without delaying appointments or treatment. With Care Credit you can pay for out of pocket expenses for your surgery right away and then make convenient monthly payments.

Learn more about how to apply for care credit.

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    © 2016 by Belmont / Harlem Surgery Center. All rights reserved. Web Development Joanne Klee Marketing Chicago.

    Belmont / Harlem Surgery Center is a physician-owned joint venture with Amita Heath. Belmont / Harlem Surgery Center is licensed and regulated by the Illinois Department of Public Health and accredited by the Joint Commission.