Please enable JavaScript in your browser to complete this form.Submitter NameSubmitter Email *Location *OR (St. Lukes)Endo (St. Lukes)IR (St. Lukes)OB (St. Lukes)OR (SEMC)CTOR (SEMC)Hybrid Room (SEMC)IR (SEMC)Cath Lab (SEMC)EP Lab (SEMC)Cancel SurgeryCancel SurgeryCancel Surgery Reason:Change Date of SurgeryFromChange Date - ToToPatient InformationPatient Name *FirstLastAddressDate of BirthHome PhoneAlternate PhonePatient EmailPatient ClassAmbulatoryInpatientOutpatient (Minor)AM AdmitOP Bed AssignmentCase Classification *ElectiveSchedule in 30 MinutesSchedule in 1 HourSchedule in 6 HoursSchedule in 12 HoursSchedule in 24 HoursProcedure InformationRequested Date of ProcedureRequested Time of ProcedureDiagnosis #1Diagnosis #2Diagnosis #3Diagnosis Code #1Diagnosis Code #2Diagnosis Code #3Surgeon or Radiologist #1Surgeon or Radiologist #2Surgeon or Radiologist #3Assistant #1Assistant #2Assistant #3Procedure #1Procedure #2Procedure #3Procedure Code #1Procedure Code #2Procedure Code #3Type of AnesthesiaLocalOtherGeneralNurse IV SedationMonitored AnesthesiaEstimated LengthAdditional CommentsInterpreter Services Needed:YesNoInterpreter Language Needed:Health Status *HealthyUnhealthyAcuity Level *LowMediumHighSpecial Needs (Equipment)Special Post-op Unit RequestCCUIMCUICUPre-Admission ScreeningPlease check appropriate type of pre-surgical screening:PAT 60/LabsPAT 30/PhoneCOVIDCrutch TrainingMid-LevelPAT 60/Labs - Date and TimeDateTimePAT 30/Phone - Date and TimeDateTimeCOVID - Date and TimeDateTimeIs COVID test is being done at another location?YesNoCovid LocationCrutch Training - Date and TimeDateTimeMid-Level - Date and TimeDateTimeForm ID:SubmitContactSurgical Scheduling 315-624-4020 315-624-4024 315-624-4027
