Amended Surgery Scheduling Request Form - Mercy Health 2026

1. Click ‘Get Form’ to open the Amended Surgery Scheduling Request Form in the editor.
2. Begin by entering the 'Date of Requested Surgery' and the 'Patient Full Name' along with their 'Date of Birth'. This information is crucial for identifying the patient.
3. Indicate who is completing the form by filling in their name and contact number. Select the patient's gender by checking either Male or Female.
4. In the 'Surgeon(s)' section, provide the first and last names of the surgeon. Specify the admit status by selecting one of the options: Ambulatory Surgery, Inpatient, or Inpatient One Day Prior to Surgery.
5. If there are changes in time or date, fill in both the original and new dates and times accordingly. Ensure you include any changes in permit/procedure details as well.
6. For anesthesia type changes, specify both original and new types. If applicable, provide additional details regarding special requests or equipment needed.
7. If you need to cancel a case, check the appropriate box and provide a reason for cancellation. Don't forget to sign and date at the bottom of the form.

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