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Procedure / Surgical Services Posting Sheet for Web Portal
Location *

 
Surgery Date *
  

 
PATIENT INFORMATION
 
First Name *

 
Last Name *

 
Gender *
 Male    Female

 
Address *

 
 

 
City/State/Zip *
     

 
Phone *
 (home)
 
 (cell)
 
 (work)

 
Date of Birth *
  /     /  

 
Age *

 
SSN # *
(last four digits)

 
Height / Weight *
 (inches)    (pounds)

 
BMI

 
NEXT OF KIN/EMERGENCY CONTACT
 
Contact Name

 
Relationship

 
Phone
 (home)
 
 (cell)
 
 (work)

 
WORKMAN'S COMP
 
 Yes    No
 
 
INSURANCE INFORMATION
 
Is patient same as subscriber?    Yes    No
 
Covered by insurance? *    Yes    No
 
Insurance #1
 
Name

 
ID#

 
Group#

 
Subscriber Name

 
Relationship to Patient

 
Date of Birth
  /     /  

 
SSN #
 -   - 

 
Insurance Phone

 
Pre-Cert #

 
Insurance #2
 
Name

 
ID#

 
Group#

 
Subscriber Name

 
Relationship to Patient

 
Date of Birth
  /     /  

 
SSN #
 -   - 

 
Insurance Phone

 
Pre-Cert #

 
PAST MEDICAL HISTORY *
 
 CAD (Coronary Artery Disease)
 PVD (Peripheral Vascular Disease)
 Lung Disease
 Stroke
 Kidney Failure
 Diabetes
 Pt on Anticoagulant Therapy (ie Coumadin, Plavix, Lovenox, ASA)
      Stop Date 
 Other 
 None
 
SURGERY INFORMATION
 
CPT CODE(S) *
     

 
Surgical Procedure *

 
ICD-10 CODE(S)
     

 
Surgical Diagnosis *

 
SURGEON
 
Surgeon Name *

 
Surgeon Email *

 
Scheduled By Email *

 
Surgery Length *
(hours)   (minutes)

 
2nd Surgeon

 
Assisting Surgeon

 
Type of Anesthesia

 
 Need SA (surgical assistant) 
 
 
SPECIAL SURGICAL NEEDS
 
Allergies
 Latex
 Other  
 

 
X-Ray:   Portable    C-ARM
 
Does patient currently have any implantable devices? *
 Yes    No
 
Pacemakers/AICD-additional information required: Type of pacemaker/implant, Date placed and date of last battery change, Effect of magnet, Cardiology assessment of current function
 
Type of Implants/Devices
 
 
Date
 
Blood/Contact/Airborne Precautions
 
 
Instrument/Equipment/Tables
 
 
Patient Position/Device
 
 
 
ELECTRONIC SIGNATURE
 
 Physicians Sign *   Last 4 Digits SSN -