Surgery Complex Case Notification Form
Please complete this form to notify the surgical team of a complex case. Ensure all details are accurate to assist with triage and preparation.
Patient Initials
*
Patient Age
*
Patient Gender
*
Male
Female
Other
Prefer not to say
Primary Diagnosis
*
Procedure Type
*
Please Select
Cardiac Surgery
Neurosurgery
Orthopedic Surgery
General Surgery
Vascular Surgery
Other
Urgency Level
*
Emergent
Urgent
Elective
Main Surgeon
*
Anesthesia Required
*
General Anesthesia
Regional Anesthesia
Local Anesthesia
To be determined
Anticipated Complications
Preferred Surgery Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit Notification
Should be Empty: