Procedure Form
Fax to 503-364-0081
PROCEDURE FORM FOR SURGERY TO BE COMPLETED BY DOCTOR PERFORMING PROCEDURE AND RETURNED TO NORTHBANK 24 HOURS PRIOR TO PROCEDURE. THIS INFORMATION WILL BE USED TO COMPLETE THE FACILITY CONSENT AND TO ENSURE THAT THE CONSENT IS ACCURATE.
PATIENT NAME:
DATE OF PROCEDURE:
PROCEDURE TO BE PERFORMED
(PLEASE DO NOT ABBREVIATE)
DOCTOR SIGNATURE / INITIALS:
NOTES
PRINT FORM
