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Procedures on Demand _ Surgery Scheduling Form

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Procedures on Demand _ Surgery Scheduling Form Powered By Docstoc
					                                      Shirish A. Amin, M.D., P.C.
                                       (724) 465-6650 (phone)
                                         (724) 357-9281 (fax)

                  PROCEDURE/CONSULT ON DEMAND

Patient’s Name                                              Date

Birth Date                                                  Social Security #

Phone (h)                                                   Phone (w)

Street Address                                              City, State, & Zip

Primary Insurance Company                                   Policy Number/Group Number

Secondary Insurance Company                                 Policy Number/Group Number

Referral requirements met?           Yes         No      Pending
                                            SCREENING QUESTIONS
Is the patient on Coumadin, Plavix, or Lovenox?             Is the patient on Aspirin or Ibuprofen?
 Yes*     No                                               Yes*     No
*Must be off of blood thinners for at least 5 days          *Must be off Aspirin or Ibuprofen for 5 days
Is the patient Diabetic?     Yes*           No            Does the patient have any artificial valves?
                                                             Yes*     No
*Must check with Dr. Amin about dosages                     *Must check with Dr. Amin about antibiotics
Does the patient have a pacemaker or defibrillator?         Has the patient had any stroke/MI in the last 6
 Yes*     No                                              months?       Yes*  No
* Must check with Dr. Amin before scheduling                * Must check with Dr. Amin before scheduling
ADDITIONAL PERTINENT PMH:                                    Is the patient able to register      Yes      No*
                                                            *Why?
Is the patient allergic to Latex?      Yes     No         Medications
Any other drug allergies?            Yes*     No
*List




Referring Physician                                         Phone

Procedure                                                   Diagnosis

Anesthesia                   IVCS            SBA          ASA Physical Status: 1 – Normal/healthy, 2
                                                            – mild systemic disease, 3 – severe systemic
ASA Physical Status     1      2           3 4          disease, and 4 – severe systemic disease
          (see classifications in next box)                 with threat to life


Patients will be contacted by our office to schedule the procedure. The
patient will need to come to the office to receive instructions and prep.

1265 Wayne Avenue, 119 Professional Center, Suite 301, Indiana, PA 15701
                   www.shirishaminmdpc-dhci.com

				
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