GI Lab Scheduling

AHMC/Anaheim Regional Medical Center GI Lab Scheduling
Scheduling form completed by:
Office Number/Direct Line:
Patient’s Legal Name (First):
Patient’s Legal Name (Last):
Patient’s Middle Initial:
Daytime Phone #:
Evening Phone #:
Medical Insurance
Insurance Authorization Number For Surgery:
Surgeon’s Name:
Assistant Name:
Proctor (if applicable):
Diagnosis (Description Required):
CPT Code:
Estimated Length of Stay:
Procedure/Surgery:

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Patient Status:
Outpatient
In-Patient
AM Admit
Anesthesia Procedure/Type:
General
MAC
Other
Requested Date of Surgery:
Requested Surgery Start Time:
Time Required:
Pre-Admission Screening Appt:
Primary Care Physician:
Medical Group:
Medical/Cardiac Clearance From:
Labs Done At:
H&P Completed By:
Special Equipment Requests

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Special Vendor Requests:
Developmental Issues: