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Amended Surgery Scheduling Request Form - Mercy Health 2026
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- Click ‘Get Form’ to open the Amended Surgery Scheduling Request Form in the editor.
- 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.
- 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.
- 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.
- 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.
- For anesthesia type changes, specify both original and new types. If applicable, provide additional details regarding special requests or equipment needed.
- 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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