Date: _____/____/____ Date of Surgery: ____/ _____ /_____ Start Time : _________H
Room No : ________________________________ Surgeon : ________________________________________________
PATIENT INFORMATION:
Name: ______________________________________ Age : ______ PHIN : _______________________________________
Address: _____________________________________________________________________________________________
Contact Number: __________________________ Date of Birth: ______/ _____/ _____ Gender: □ Male □ Female
INSURANCE INFORMATION:
Primary Insurance: _____________________________________________ Guarantor: ______________________________
Secondary Insurance: ___________________________________________ Guarantor: _____________________________
SCHEDULED PROCEDURE INFORMATION Laterality ICD- 10
Pre-op diagnosis: □ Right
□ Left
□ Bilateral
Procedure: □ Right
□ Left
□ Bilateral
Pre-op Diagnosis: □ Right
□ Left
□ Bilateral
Procedure: □ Right
□ Left
□ Bilateral
ANESTHESIA PROVIDER REQUIRED: □ YES □ NO □ Local Anesthesia Type of Anesthesia: _________________
Name of Anesthesiologist: _______________________________________________________________________________
Patient Admission Plan: □ To be admitted □ Discharge on DOS □ ASC extended recovery □ Procedure Duration: ________
First assistant Requested: □ Yes □ No Name of 1st Assistant: ___________________________________
Second Assistant Requested: □ Yes □ No Name of 2nd Assistant: __________________________________
Studies completed related to this procedure: □ CT Scan □ X- ray □ MRI □ Mammogram □ Ultrasound □ Others___________
Location where completed: ______________________________________________________________________________
Surgical Equipment Required: □ C- arm □ Others: ___________________________________________________________
Equipment: __________________________________________________________________________________________
__________________________________________________________________________________________
Vendor notified by surgeon: □ Yes □ No Vendor’s Name: __________________________________________________
Contact Number: ________________________________________________
LABORATORY/BLOOD BANK NOTIFICATIONS: Frozen Section Anticipated: □ Yes □ No
Name of Facility: _________________________________________________ Contact Number: ______________________
Blood bank: No. of Units _______________□ PRCB □ FFP □ Platelet Conc. □ Whole Blood □ Modified PRBC
Crossmatch: □ Yes □ No Remarks: ___________________________________________________________________
PRE-SURGICAL TESTING INFORMATION:
Patient’s weight: _______________ kgs Length: ________________ cms.
Have implanted Cardiac Device: □ Yes □ No Type of Device : ______________________________________________
ALL INFORMATION MUST BE RECEIVED IN OPERATING ROOM 24 HOURS PRIOR TO DATE OF SURGERY * provide in duplicate copy
Endorsed By: Received by:
_________________________________________________________ __________________________________________________
SIGNATURE OVER PRINTED NAME, Date and Time SIGNATURE OVER PRINTED NAME, Date and Tine
NURSE ON DUTY OR NURSE ON DUTY
Verified by:
_____________________________________________________
SIGNATURE OVER PRINTED NAME, Date and Time
Billing / Cashier
SURGICAL POSTING REQUEST FORM
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