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
[pic]
Patient Information Label
|Precertification |
|Insurance Company: |
|Name: |
|Date: |
|Auth #: |
|Policy #: |
CASE #: __________________________
Tentative CASE TIME:__________
Booked By: _____________________
................
................
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