Surgery Scheduling: Providence Saint Joseph Medical Center

Surgery Scheduling: St. Joseph Medical Center (So Cal)

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Note: This is only a surgery scheduling request. After submission, a surgery scheduler will notify you at the number/email provided with a booking number as confirmation. All information must be provided. Incomplete information will delay case booking.

	Surgery scheduler's name*

	Surgery scheduler's email address*

	Surgery scheduler's phone number

	Surgeon's name*

	Procedure Date*

	Procedure Time* Enter as xx:xx

Male or female?

	Male
	Female

	Epic MRN#

	Patient's last and first name*

	Patient's date of birth*

	Patient SSN#

	Patient's full address: street, city, state and ZIP code

	Patient Home Phone #*

	Patient Cell Phone #*

	Patient type*

	H&P doctor

	Anesthesia type

	Patient diagnosis wording and ICD-10 code*

	Procedure CPT code*

	Procedure Wording*

	Estimated case length*

	Positioning, Special requests, and/or Vendor supported equipment/services/implants* C-ARM, ESWL, OTHER, specify type (eg. Holmium, Oculight, CO2, Thulium, Nerve Monitor/NIM, etc). If none, write "N/A"

Latex allergy?

	Yes
	No

	Insurance type*

	Subscriber ID*

	Authorization #

Submit