Surgery CHANGE Request
FAX: (503) 814-2038
(All Fields Required)
Fax Sent By:
Surgeon:
Marcus A. East, M.D.
Ryan W. Lapour, M.D.
John G. Dodd, D.O.
Patient Name:
DOB:
Current Surgery Date:
CSN#:
Reschedule
New Date Required:
Change has been confirmed with RNFA
Cancel
Cancellation Reason Required:
Change has been confirmed with RNFA
Modification to Scheduled Case
Change to Track 1
Select all that apply:
Procedure
Equipment
Laterality
Diagnosis
Admission Type
Other
Notes:
OR Scheduling Office Use Only
Changed By:
Surgery Time:
To Follow:
Scheduler Notes:
Revised: 3/2018
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