Plastic/ENT/OPH Surgery Scheduling Request
FAX: (503) 814-2038
Request Date:
Request time:
Block Time
OR
Time Held
Case Order (1,2,3):
Hospital RNFA Pre-Approved
Hospital RNFA Denied
No Assist Required
Fax Sent By:
Surgeon:
Marcus A. East, M.D.
Ryan W. Lapour, M.D.
John G. Dodd, D.O.
Assistant (Include Private RNFA):
Patient Full Name (Last, First, Middle Initial):
M
F
Height:
ft
in
Weight:
lbs
MRN if known:
Birthdate:
Last 4 digits of SSN:
Primary Contact #:
Alternate Contact #:
Patient Email:
CPT Codes:
ICD-10 Codes:
Admission Type:
Surgery Admit (to inpatient)
Surgery Admit-PM (day prior)
Inpatient (already in-house)
Outpatient Procedure
Outpatient Procedure Ext.
Procedure(s) full description including laterality (procedure & consent wording must match):
Anesthesia Type:
General
Spinal
MAC
Choice
Epidural
Local (No Anesthesiologist)
Implant(s) / supply and special equipment needs:
Pertinent Information:
Position:
Standard
Supine
Lateral
Other:
Other needs:
PHT Testing
Clinitron Bed
Use Surgeon's average time?
Yes
No
If No, length requested?
Films/mamms required to be viewed in room?
If yes, where done?
Pre-Surgical Screening Pertinent Information
Pre-Op Date:
Post-Op Date:
Pt is taking Anticoagulate / Antiplatelet,
Pre-Op Plan:
Dialysis Plan:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Pacer (include copy of pacer card)
ICD
Other implantable device (Explain):
Labs / EKG done outside of Salem Hospital / Salem Clinic
Location:
Interpreter Needed?
Language:
Transport plan, if Applicable:
Patient unable to sign consent.
Signer who will be available DOS:
Anesthesia Review to be Faxed to PSS (503-814-2469)
Clearence
Pulmonary
Cardiac
Medical
From:
Scheduling Office Use Only
Scheduled By:
Surgery Date:
Surgery Time:
To Follow:
RNFA Scheduled:
CSN:
Notes
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