Surgery Scheduling: Providence Cedars-Sinai Tarzana Medical Center

Surgery Scheduling: Cedars-Sinai Tarzana

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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.

	Your name*

	Surgeon's name & assist*

	Contact email address*

	Contact phone*

	Site/laterality

Needs RNFA?

	Yes
	No

	Preferred date and time of surgery (xx/xx/xx - xx:xx x.m.)

	Patient's last name and first name

	SSN#

	Patient's date of birth

Male or female?

	Male
	Female

	* The following must be provided if patient is NOT in-house at time of request!*

	Patient's address, city, state and ZIP code

	Patient's home/mobile phone #

Patient class

	Outpatient
	Surgery admit

Need a bed to stay overnight?

	Yes
	No

	Patient diagnosis wording and ICD-10 code*

	Procedure wording and CPT code*

	Anesthesia type

	Length of surgery

	Name of insurance

	Subscriber name

	Subscriber ID #

	Authorization #

	Equipment needed/special needs/implants/positioning* If none, write "none"

	Labs (H&P doctor)

Submit