Same-day Surgery 2026

1. Click ‘Get Form’ to open the Same-day Surgery document in the editor.
2. Begin by entering the patient's name in the designated field. This ensures that all information is accurately linked to the correct individual.
3. Next, fill in the patient's date of birth (DOB) to confirm eligibility for the procedure.
4. Provide the parent's name and contact phone number. This information is crucial for communication regarding the surgery process.
5. Indicate whether the patient was self-referred, referred by a primary care provider (PCP), or another source by checking the appropriate box.
6. Complete the section on how you heard about the program, as this helps us improve outreach efforts.
7. Fill in the number of episodes of otitis media experienced in both the past 6 months and 12 months. This data is essential for assessing eligibility.
8. Record the approximate date of the last ear infection to provide context for medical history.
9. Address any concerns about hearing or speech in the provided space, as this may impact treatment decisions.
10. Lastly, note any other risk factors related to otitis media that may be relevant for your child's case.

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