Surgery Scheduling | Carondelet Health Network

Procedure Information

Hospital ^*

Scheduler's Email Address

Status ^*

Physician's Name ^*

Procedure ^*

Is This Case ^*

Side

Patient has Pacemakter/Defib? ^*

Yes

Facility where patient is located? ^*

Diagnosis ^*

Anes Group ^*

Type ^*

CPT Codes ^*

ICD-10 Codes ^*

Date of Procedure ^*

mm/dd/yyyy

Patient Needs C.A.R.E. Clinic ^*

Yes

Requests

Start Time

Amount of Time

Comments

Patient Information

Patient First Name ^*

Patient Middle Name

Patient Last Name ^*

Zip Code ^*

Select Gender

Birth Date ^*

mm/dd/yyyy

Address

City

State

Home Number

999-999-9999

Work Phone Number

999-999-9999

Cell Phone Number

999-999-9999

History of MRSA or VRE? ^*

Yes

Insurance Information

Insurance #1 ^*

Group

Authorization ^*

Ins #1 Comments

Insurance #2

Group

Authorization

Ins #2 Comments

Surgery Scheduling at Carondelet

Procedure Information

Patient Information

Insurance Information

Health Professionals