Attending Surgeon: ____________________________ Other ...



8

Attending Surgeon: Daniel Wiznia MD Other Surgeon/ Resident: _________________________

Assistant: Rene King Phone Number: 785- 3714 Beeper Number: _______________________ Fax Number: 785-7132

| | | |

|Admit Date: ____/ ____/ _____ |Location: |Time Preferred: ___________ |

|Date of Surgery: ____/ ____/ _____ |( Ambulatory ( Main SRC OR |Anticipated Length of Stay: ____ |

|Type of Admit: ( Express Admission |( McGivney Same Day SRC OR | |

|( Outpatient/Ambulatory |( Pedi OR ( Litho |( Post Op ICU Bed |

|( Inpatient Admission |( Cysto ( Special | |

|( Inhouse Loc: ______________________ |( Smilow Procedure | |

| |Room | |

|Patient| |

|Informa| |

|tion | |

| | |

| | |

| | |

| |Patient: Allergies: ___________________________________________________________ ( Known Latex Allergy |

| |Special Needs: |

| |( Hard of Hearing ( Deaf –needs sign language interpreter ( Interpreter Required / Language: ____________________________ |

| |( Other: ___________________________________________________________________________________________________ |

|Surgica| |

|l |Anticipated Anesthesia: ( Epidural ( Gen-Epidural ( General ( General-PNB ( Gen-Spinal ( Local ( MAC |

|Informa|( None ( PNB ( Spinal ( Other _______________________________________________________________________ |

|tion | |

| |Side of Body: ( Left ( Right ( Bilateral |

| |ICD-10 Codes: _____________________________________ Diagnosis: _____________________________________ |

| |Surgeon’s Description: ______________________________________________________________________________ |

| |___________________________________________________CPT Code: _____________________________________ |

| |Estimated Length of Surgery: __________________________________ |

|PRE -OP |Position |OR Table |Attachments |Instrumentation |

| | | | | |

|( Chest X-Ray |( Supine |( Regular O.R. Table |( Pegboard |( Total knee |

|( EKG |( Lateral |( OSI Flat Top | |( Partial knee |

|( Urinalysis | |( HANA | |( Total hip |

|( PT/PTT | | | | |

|( CBC | | | | |

|( Clot to BB (T & S) | | | | |

|( Lytes | | | | |

|Zimmer Biomet, Paul Shortt, | | | | |

|203.997.6530 | | | | |

|paul.shortt@ | | | | |

| | | | | |

|Depuy Synthes, J & J , Eric | | | | |

|Urbinati, | | | | |

|eurbinat@its. | | | | |

|(860)335-6759  | | | | |

| | | | | |

|Smith&Nephew, Steve Dodge, | | | | |

|Sdodge8@ | | | | |

|203-565-3569 | | | | |

| | | | | |

|Stryker, John DePalma | | | | |

|203-641-2324 | | | | |

|john.depalma@ | | | | |

| |Blood Bank |Company |Equipment |Other Equipment |

| |( Type and Cross # Units ________ |( Smith and Nephew | |( Cell Saver |

| |( Autologous Blood # Units ________ |System: |( OrthAlign |( Fluoroscopy |

| |Ordered On: _____/_____/_____ | |( Intellijoint |( Neuromonitoring |

| |Script Sent: _____/_____/_____ |( Zimmer |( MAKO | |

| | |System: |( High speed burr | |

| | | |( Visionaire | |

| | |( Stryker | | |

| | |System: | | |

| | | | | |

| | |( J&J Depuy Synthes | | |

| | |System: | | |

-----------------------

Cases for day of and weekends

Phone: 688-2360 Fax: 688-4768

SURGICAL BOOKING

Phone: 688-8888 Fax: 688-1000

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Patient Information Label

|Precertification |

|Insurance Company: |

|Name: |

|Date: |

|Auth #: |

|Policy #: |

CASE #: __________________________

Tentative CASE TIME:__________

Booked By: _____________________

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