Surgical Booking Request

SiteHealth Record #Encounter #

Date Submitted (yyyy-Mon-dd)Date Admitting Received (yyyy-Mon-dd)Admitting Surgeon

Last NameFirst NameMiddleAgeDate of Birth

 (yyyy-Mon-dd)  Female          MalePHN/Unique Lifetime IdentifierFederal Gov’t / Out of Province #/Self-pay / Uninsured Yes            NoAddress

 (Apt / Street No.)CityProvincePostal CodeHome PhoneCell PhoneBusiness Phone 

                                                   (ext.                  )Parent(s) / Legal Guardian NamePhoneFamily PhysicianWCB Claim #

Does patient have cancer related to this surgery?  Yes            No            SuspectedAre there any dates the patient is unavailable? No            Yes, from                                                 to                                                 

Surgery Date (yyyy-Mon-dd)Decision to Treat Date (yyyy-Mon-dd)Ready to Treat Date (yyyy-Mon-dd)Referral Date to Surgeon (yyyy-Mon-dd)

PAC Yes     NoPre-op Assessment Clinic Date (yyyy-Mon-dd)Pre-Op Assessment Referral     ICU      Internist       Anaesthesiologist        Referring Physician Name

Admit Category Within  3 days  1 week  2 weeks  3 weeks  4 weeks  6 weeks  12 weeks  16 weeks  26 weeks

Admit Type (select one) Urgent  Elective Admit                  days Pre-Op  Day Surgery  24 Hour Stay Admit Day of Procedure  Medical  ICU Post-Op Step down / Intermediate Care Unit  Observation Post-Op  Admit                  days post-op

Provisional DiagnosispCATS / aCATS Diagnosis Code

Procedure 1CodeDescription Right      Left       Bilateral         Skin to Skin Time

SurgeonInsured Procedure No        

Procedure 2CodeDescription Right      Left       Bilateral         Skin to Skin Time

SurgeonInsured Procedure No        

Special O.R. Equipment/Prosthesis Assistant required Yes            NoFluoroscopy / C-arm Yes            No

Required Anaesthetic  General  Regional (spinal, epidural, peripheral)  Procedural Sedation/Analgesia (without anaesthesia support) Local   IV Regional (Bier)  Monitored Anaesthetic Care (with anaesthesia support)      

Special Medical Concerns / Needs / Allergies

 Autologous Blood  Creutzfeldt-Jakob Disease precautions  Type 1 Diabetes  Type 2 Diabetes  Antibiotic Resistant Organisms  Latex Allergy          Malignant Hyperthermia  BMI                   Obstructive Sleep ApneaNameSignatureDate

 (yyyy-Mon-dd)

Attachments Prosthesis  Hip  Knee  Spine  Other (specify)                                                                             Lab History  Orders  Consult      Legal Guardian Consent  Consent  ECG            Creutzfeldt-Jakob Disease Risk Assessment Tool  Self / Care-Giver Assessment  Other (specify)                                                                  

PostponementReason for PostponementRescheduled Surgery  Date (yyyy-Mon-dd)Rescheduled Admission Date (yyyy-Mon-dd)Initials

18277pos(Rev2014-06)

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Original - Admitting      Copy 1 - Pre-Op Assessment / Health Record      Copy 2 - Physician

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