Order for Consent to be Completed Day of Surgery
Reason for this request:
 
If reason is to change originally scheduled procedure, Schedule "change form" with matching new consent wording must be sent to surgery scheduler.
Patient Name:
DOB:  
CSN:
Date of Surgery:  
Consent wording must match procedure scheduled and orders / No abbreviations

OR

{
}
Ordering Physician:
Signature:
Date:
Order for day of surgery consent - 2018