NORTH QUEENS SURGICAL CENTER
Today's Date
/
Month
/
Day
Year
Date
PATIENT INFORMATION: (Please provide 2 phone numbers)
Name
FIRST NAME
LAST NAME
ADDRESS
HOME #
WORK #
CELL #
Sex
Male
Female
SSN
DOB
Email address
example@example.com
PROCEDURE INFORMATION:
DATE OF SURGERY
/
Month
/
Day
Year
Date
PROCEDURE CPT CODE(S)
PROCEDURE DESCRIPTION (as will be shown on consent)
Which Eye?
Please Select
Right Eye
Left Eye
DIAGNOSIS CODE(S)
DIAGNOSIS
Anesthesia
Topical
Peribulbar
SPECIAL REQUESTS (Implant / Equipment / Navigation / Medication)
HIPAA CONSENT TO LEAVE VOICE MESSAGE ON PATIENT VOICEMAIL
YES
NO
RELIGIOUS OR CULTURAL NEEDS
INSURANCE INFORMATION: Commercial, Medicare, Medicaid (MUST ATTACH COPY OF INSURANCE CARD)
Take Photo of Insurance Card
NAME OF INSURANCE CARRIER
PATIENT ID OR CLAIM: #
INSURANCE APPROVAL OR AUTHORIZATION #
North Queens Surgical Center
Preference Card
PCPs Name
HISTORY OF PRESENT ILLNESS
Preview PDF
Submit
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