Keck NSG Surgery Request Form

Patient Information

Patient Name

Date of Birth

Medical Record Number

Insurance Carrier

Policy Number

Home Phone

Cell Phone

Surgical Plan

Surgery Date

Start Time

Hours

Anticipated Days in-house

Primary Surgeon

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Assisting Surgeon

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Diagnosis

Procedure

ICD-10 Code

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CPT Code

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Other

Intra-op Rep:

Navigation

Stryker

Stealth

Equipment Checklist

Pre-Operative Requirements

Preoperative Clearance Determination

PCP Information

PCP

Phone

Fax

START Consult

START Phone Consult

Utilization Review

Utilization Phone

Fax

Pre-Arrival Status

Pre-Arrival Notified

Pre-Arrival Cleared

Additional Notes

Digital Signature Required

Surgeon signature required

Click and drag to sign

Keck Medical Centerof USC

Surgery Request Form

Position

Anesthesia

Blood

Implants

Intraoperative Monitoring

PCP Information

START Consult

Utilization Review

Pre-Arrival Status