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: 450 characters remaining 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 450 characters remaining Special Vendor Requests: Developmental Issues: Submit