Operating Room Surgical Procedure Slip Form
Please complete all relevant details for the scheduled surgical procedure. This form is for operating room coordination only; do not include sensitive personal or financial information.
Patient Reference (Initials or Case Code)
*
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Scheduled Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Operating Room Number
*
Primary Surgeon Name
*
First Name
Last Name
Procedure Type
*
Anesthesia Type
*
Please Select
General
Regional
Local
Sedation
Other
Supporting Staff (List Names or Roles)
Special Equipment or Preparation Notes
Additional Comments
Submit
Should be Empty: