GI Lab Scheduling | Anaheim Regional Medical Center

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:

Anesthesia Procedure/Type:

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: