Medical Procedure Site Identification Form
Use this form to identify the intended procedure site, procedure details, and any notes needed to confirm the correct site before the procedure. This is a general-use form and is not presented as HIPAA compliant.
Patient and Procedure Details
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Procedure Name or Type
*
Ordering Clinician or Surgeon Name
*
Procedure Date
*
-
Month
-
Day
Year
Date
Site Identification and Confirmation
Procedure Site
*
Please Select
Head
Neck
Chest
Abdomen
Back
Left Arm
Right Arm
Left Leg
Right Leg
Both Sides
Other
Laterality Confirmation
*
Left
Right
Bilateral
Not Applicable
Site Marking Status
*
Marked
Not Marked
Not Applicable
Site Identification Notes
Administrative Follow-up
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Comments or Special Instructions
Submit
Should be Empty: