Surgery Scheduling Form
Surgery Scheduling Form
Requested Date: Requested Time:
Patient Name: DOB: Gender (M/F):
Parent/Guardian (if patient is a minor):
Insurance:
Phone (Home): (Work): (Cell):
Surgeon: Clinic:
Assistant:
Referring Doctor: Clinic:
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|Critical components (to be completed by surgeon/physician performing procedure) |
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|Pre-Op Diagnosis: |
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|Procedure to be Performed: ___________________________________________________________ |
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|Procedure Location: Right Left Bilateral |
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|Other Procedure Location Information (e.g. digit involved):__________________________________ |
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|__________________________________________________________________________________ |
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|Physician Signature:___________________________________________________ |
Case Length: Anesthesia ( circle): General MAC Local Regional
Pt. Type (circle Type): AM SD 23 IP
Positioning:
Infection/Isolation: (Y) (N) If yes, what type?
Allergies:
Interpreter? (Y) (N) Language Needed?
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