Surgery Scheduling Information Form

Surgery Scheduling Information Form
PATIENT INFORMATION
Patient Name
First NameMiddle NameLast Name
Sex
FemaleMale
Requested Date/Time
MonthDayYear
DateHourMinutesAM/PM Option
Patient Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Home Phone
Area CodePhone Number
Cell Phone
Area CodePhone Number
Marital Status
SingleMarried
Weight
Height
EMERGENCY & REFERRAL
Information about person to contact in case of an emergency
Name
First NameLast Name
Relationship
Phone
Area CodePhone Number
SURGERY INFORMATION
Date of Procedure
MonthDayYear
Date
Surgeon Name
First NameLast Name
Surgeon's Number
Area CodePhone Number
Diagnosis
Procedure
Procedure Length
Preop testing
YesNo
Anesthesia type
GeneralMacLocalSpinal
Pain Block
YesNo
Special Equipment
Medical History of Patient
Medical or surgical history, latex precaution or allergy, diabetes, seizures.. ?
Form Completed by
Date
MonthDayYear
Date
Signature
Clear
Should be Empty: