Surgical Scheduling Request
To request a new case to be scheduled at Coral Surgery Center, please complete the below form with as much information as you have available. Once you click the Submit button, our team will review and contact you for next steps. Thank you for trusting our team to care for your patient!!! This Form is fully HIPPA COMPLIANT
Surgeon Name
*
First Name
Last Name
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
*
example@example.com
Type of Procedure
*
Estimated Duration of Procedure (MINUTES)
*
What Type of Anesthesia
*
General
MAC
Local
Ideal Surgical Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
If Ideal is unavailable, Acceptable Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Who Submit this Request
*
First Name
Last Name
Submitter Email
*
example@example.com
Photo ID
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Has Surgeon Personally Reviewed ALL Medical Clearance Documentation Being Uploaded Today
Yes
No
History & Physical
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Labs
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Surgical Orders
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signed Payment Policy Form
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Case Request
Should be Empty: