ࡱ> 685  bjbjss 433333GGGGc$G@bbb&v3bbbbb33&&&b.33&b&&`R0G:u0,>F>>3bb&bbbbbbbbbbbb>bbbbbbbbb : Surgery Scheduling Form Requested Date: Requested Time: Patient Name: DOB: Gender (M/F): Parent/Guardian (if patient is a minor): Insurance: Phone (Home): (Work): (Cell): Surgeon: Clinic: Assistant: Referring Doctor: Clinic: Critical components (to be completed by surgeon/physician performing procedure) Pre-Op Diagnosis: Procedure to be Performed: ___________________________________________________________ Procedure Location: Right Left Bilateral Other Procedure Location Information (e.g. digit involved):__________________________________ __________________________________________________________________________________ Physician Signature:___________________________________________________ Case Length: Anesthesia ( circle): General MAC Local Regional Pt. Type (circle Type): AM SD 23 IP Positioning: Infection/Isolation: (Y) (N) If yes, what type? Allergies: Interpreter? (Y) (N) Language Needed? ,;<=>?QRSYZ_`ab۷zrfzr^VNChw?hb CJaJh^CJaJhb CJaJh[_CJaJhh6CJaJhCJaJhw?h%CJaJ h^h^hw?h[_CJaJhw?CJaJhL_h[_h^hw?h^hw?5#h^hL_5CJ OJQJ^JaJ #hL_hx=5CJ$OJQJ^JaJ$#hL_h[_5CJ$OJQJ^JaJ$#hL_h%5CJ$OJQJ^JaJ$=>?bc $gd d$ZZgd  $ZZZgd^ $gd^ P $gd^ t"$gd \ P$gd^$a$gdx=H I ]  @ A ʿڿҴuujfhL_hPh~DGCJaJhPh(YCJaJhPhu CJaJhPhL_5CJaJ#hPhL_5CJOJQJ^JaJhPhL_CJaJhw?hL_CJaJhw?hw?CJaJhw?CJaJh%CJaJhCJaJhw?h%CJaJhw?h[_CJaJh^CJaJ%H I \ ] A B  4$If^gdPl  #Z$If^gdPl $If^gdPl $IfgdL_l d$ZZgd d$ZZxgd@ # g^GG  !L^`Lgd. $Zgdp<~kd$$Ifl$h%  t 0644 l` ap ytP  #Z<$IfgdPl           , - 4 9 : < > @ A C D F G W Y p x ÿhb h@CJaJhp<CJaJh@hp<hw?hWUjhWUjCJhWUjh(Y6CJaJhL_h(Y6CJaJh(YCJaJhw?h(YCJaJhWUjCJaJ,# $ J K Y Z  $Zgd. $Zxgd@  #Z<gdWUj  #ZL<^`LgdWUj #L^`Lgd.  \ L^`Lgd. L^`Lgd. 21h:pw?/ =!"#$% $$If!vh5h%#vh%:V l  t 065h%` p ytPb 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~PJ_HmH nH sH tH D`D NormalCJ_HaJmH nHsH tHDA D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List j@j L_ Table Grid7:V0PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]    #  8@0(  B S  ?>@xz3333BQIL n^`o() ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.QIL         u Kml%p<a<=>w?~DGW(Yq(^L_WUj.P+4@x=b ~[_"^ 4@@UnknownG* Times New Roman5Symbol3. * ArialG5  hMS Mincho-3 fgA BCambria Math"1hhchc22!24d 2QHX ?[_2!xxSurgery Scheduling Formmcca Lenovo User Oh+'0   @ L Xdlt|Surgery Scheduling Formmcca Normal.dotm Lenovo User2Microsoft Office Word@F#@()@()2՜.+,0 hp|   Surgery Scheduling Form Title  !"#$&'()*+,./012347Root Entry F`09Data 1TableNWordDocument4SummaryInformation(%DocumentSummaryInformation8-CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q