Surgery Scheduling Request Form - DOC - DOC by m9JyfNeA

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									SURGERY/PROCEDURE ROOM SCHEDULING REQUEST FORM
UNTHSC DLAM
To be completed by PI/TECH: (Send completed form to Tito Nelson via e-mail:
snelson@hsc.unt.edu or fax to 817-735-0559)

Investigator Information:
Name of PI:                                                Telephone#
Department:                                                Protocol#
Species:                    Grant# :                       Animal ID #:
Title of protocol:
Contact persons E-mail address:
Surgeon/Person
performing procedure:
Assistant(s):
DLAM assistance required?           Yes         No (if yes, fill out information below)

DLAM Services/Assistance Needed (mark all that apply):

Perform surgery       Animal prep         Monitor anesthesia            Recover animal
Estimated time needed to perform surgery:
DLAM Surgery/Procedure Room reserved ?:              Yes           No
Surgery/Procedure Room Number requested:

Surgical dates and times requested (preferred)
Date/time:                                    Date/time:
Date/time:                                    Date/time:
Date/time:                                    Date/time:
Date/time:                                    Date/time:

DLAM
Equipment/Supplies
needed:



To be completed by DLAM Staff

Date request received:
Veterinarian in attendance:
Date Surgery Scheduled for:
Date Surgeon notified:                         Date PI notified:
Method of notification:
Comments:

								
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