Surgery Scheduling Form - PDF by mli13301

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									□ SILICON VALLEY SURGERY CENTER, L.P., 14601 S Bascom Ave, Ste 100, Los Gatos, CA 95032                                   (408) 402-0663 FAX (408) 402-7055
□ SVSCLP, dba/BASCOM SURGERY CENTER, 3803 S Bascom Ave, Ste 106, Campbell, CA 95008                                        (408) 369-9535 FAX (408) 402-7055
Business Office 3190 S. Bascom Avenue, Suite 140, San Jose CA 95124     (408) 879-1820      FAX (408) 402-0763

SILICON VALLEY SURGERY CENTER                                          SURGERY SCHEDULING FORM                                        Scheduling: (650) 289-1653          FAX (408) 519-6480
BASCOM SURGERY CENTER
                                                                                                                                   Primary
                                                     Patient:                                                                      Language                                Male        Female
 Date:                                                                      Last, First, Middle Initial

 Time:                                               Date of Birth:                                              S.S.#                                  Martial Status:   M        S   D    W

 AnesType:                                           Address

 OR Time:                                            City/State/Zip                                                                             Home Phone:

 Surgeon:                                            Employer:                                                                                  Work Phone:

 Assistant:                                          Address:                                                                                   Cell Phone:

    Diabetic       Weight > 300 lbs. _________       Procedure:
 PRE-OP TESTS:               None        EKG         Include CPT

     Labs:                                           Diagnosis
                                                     Include ICD9
 Insurance Information – Primary (if other than patient)                                                                               INSURANCE COMPANY - PRIMARY

 SUBSCRIBER                                                                                  Relationship:

 Address

 Phone (if different)                                    DOB:                                         S.S.#

 SUBSCRIBER Employer                                                                         Work Phone                                I.D. #                             Grp #:

 Address                                                                                                                               Phone:
                                                                                                                                       INSURANCE COMPANY - SECONDARY
 SUBSCRIBER                                                                                  Relationship

 Address

 Phone (if different)                                    DOB:                                         S.S.#

 SUBSCRIBER Employer                                                                         Work Phone                                I.D.#                              Grp #:

 Address                                                                                                                               Phone:

      SPECIAL EQUIPMENT/ INSTRUMENT/ IMPLANT REQUEST                                                                            WORKERS’ COMP INFO.
                                                                                             Adjuster:                         DOI:                    CL#:
                                                                                             Auth’d By:                        Phone #:
                                                                                             Date of Auth:
 Position:     Prone    Supine      Beach Chair     Lateral   Other:                         Financial Disclosure Name:                                                    Date:
                                                                                                                                                                                                6/09

								
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