Get Surgical Reservation Form - Rush University Medical Center - Rush

Filling out the Surgical Reservation Form at Rush University Medical Center is an essential step in ensuring that all necessary information is collected for your upcoming surgery. This guide will provide you with clear instructions to help you complete the form efficiently and accurately.

Follow the steps to properly complete the Surgical Reservation Form online.

1. Click the ‘Get Form’ button to obtain the Surgical Reservation Form and open it in your preferred online editor.
2. Begin by entering the patient’s full name. Include the last name, first name, and middle initial if applicable.
3. Fill in the medical record number (MR#) if available along with the patient’s date of birth.
4. Indicate the patient's sex and provide the social security number (S.S.#) along with contact numbers: work, home, and mobile.
5. Input the patient’s address to ensure proper communication.
6. Specify the requested surgery date and time to facilitate scheduling.
7. Enter the case order and name of the surgeon performing the procedure along with the admission date and surgeon’s office phone number.
8. Select the patient class, choosing between in-house/ED, inpatient/admit after surgery, observation, or outpatient.
9. Estimate the length of the surgery and provide the pre-operative diagnosis.
10. Indicate if this is an add-on case and, if so, provide the add-on date.
11. Specify if the case has been rescheduled and if so, include that information.
12. Detail the procedure(s) to be performed, including the relevant code and description. Note the laterality of the procedure if applicable.
13. Select the desired anesthesia type, and mention any additional procedure requests such as equipment or setup needs.
14. Indicate whether a latex allergy is present and if an interpreter is needed.
15. Confirm if pre-operative labs were done and specify where they were completed, if applicable.
16. List any additional tests required and specify what they are, if relevant.
17. Indicate if implants are needed and whether this is a revision case.
18. State the isolation status and preferred language, including a phone number if assistance is needed.
19. Provide primary and secondary insurance information, ensuring to fill out all relevant policy and group numbers.
20. Finally, if applicable, document any no-charge devices or implants required for the procedure.

Complete your Surgical Reservation Form online to ensure a smooth process for your upcoming surgery.