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Collects surgical location, patient demographics via a sticker area, and procedure details including patient type, requested surgery date/time, pre-surgical screening options, primary surgeon and diagnosis/procedure codes. Includes fields for anesthesia type, estimated duration, modifiers, special requests, ICU bed anticipation, frozen section, COVID testing, and scheduler confirmation with date, time, case number, and staff.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/surgery-scheduling-booking-request-form/392849/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/surgery-scheduling-booking-request-form/392849.png","ImageObject",442,249,{"name":88,"@type":89},"anakgang17","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-14","2026-09-25",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required to initiate scheduling?","Question",{"text":109,"@type":110},"Bolded and shaded data elements are required for scheduling a surgical or endoscopic procedure, and scheduling cannot be initiated without the basic information.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which pre-surgical screening options are available?",{"text":114,"@type":110},"The form lists phone call screening (typically 2–3 days prior), on-site PSS visit within 7 days (including diagnostic orders), and NP visit (Boise only).",{"name":116,"@type":107,"acceptedAnswer":117},"What procedure and planning details must be completed?",{"text":118,"@type":110},"It requests patient type, surgery date/time request, diagnosis and procedure with ICD-10 and CPT codes, anesthesia type, estimated duration, modifiers and side selection, plus special requests, ICU bed anticipation, frozen section, and confirmation by the surgery scheduler.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},392849,1791245852,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962090883568,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","| SURGERY SCHEDULING – BOOKING REQUEST FORM | Phone: (208) 367-3655; or toll-free (844) 799-3199 Fax: (208) 367-3646; or toll-free (844) 799-3200 |\n| --- | --- |\n\n• Bolded and shaded areas indicate data elements required when scheduling a surgical or endoscopic procedure.  \n• Scheduling of procedure cannot be initiated without this basic information.  \n\n| Surgical Location/ Area |  BOISE\u003Cbr> Main  CVOR\u003Cbr> Day Surgery  Endoscopy |  NAMPA\u003Cbr> Main  Surgery Center\u003Cbr> Endoscopy |  ONTARIO\u003Cbr> Main\u003Cbr> Endoscopy |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Attach/Send Demographics Form |  |  |  |  Yes |  |\n| Attach/Send Referral Form\u003Cbr>(PCP to Specialist Insurance referral on required insurances) |  |  |  |  Yes |  No |\n\n Office Scheduler  Name: Ph: Fax:  \n\n| Or place patient sticker here PATIENT INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Last Name |  |  |  |  | Gender |  |  |  Male\u003Cbr> Female |  |  | MRSA Hx\u003Cbr>Latex Alx |  |  Yes\u003Cbr> Yes |  |  No\u003Cbr> No |  |  Active |\n| First Name |  |  |  |  | DOB\u003Cbr>mm-dd-yyyy  |  |  |  |  |  | Interpreter Svcs |  |  Yes |  |  No |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  | Language: |  |  |  |  |\n| PROCEDURE INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Patient Type Must check one |  Outpatient  Outpatient with 23 hour observation  Inpatient/to be admitted |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Surgery Date/Time Request |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Pre Surgical Screening | | Phone Call (usually 2-3 days prior to procedure date) On Site PSS Visit (w/in 7 days of procedure date, includes diagnostic orders)\u003Cbr>NP Visit (Boise only) |  |  |  |  |  |  |  |  |  | } Must\u003Cbr>check one | Preferred dates/times: |  |  |  |  |\n| Primary Surgeon | \u003Cbr>Assistant\u003Cbr>Surgeon |  |  |  |  |  |  |  |  |  |  |  |  request 2nd Scrub |  |  |  |  |\n| Diagnosis\u003Cbr>Procedure |  |  |  |  |  |  |  |  |  |  |  |  |  | ICD-10\u003Cbr>Code |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  | CPT Code(s) |  |  |  |\n| Modifier (if applicable) |  Left  Right  Bilateral |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Estimated Duration (min) | (skin to skin) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Anesthesia Type |  General  Choice  MAC  Spinal  Epidural  Block: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | PROCEDURE PLAN |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Special Requests |  Wound Vac  Mesh  Other  Specialty Trays/Implants:\u003Cbr> Custom order/Special order implants  Vendor notified  OR notified  N/A |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| ICU bed anticipated |  Yes  No |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Frozen Section |  Yes  No |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Does patient require COVID testing? |  |  |  Yes  No |  |  | Other |  |  |  |  |  |  |  |  |  |  |  |\n| Confirmation (completed by surgery scheduler) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | Date: |  |  | Time: |  |  | Case \\#: |  |  |  |  |  | Scheduled By:\u003Cbr>Date: |  |  |  |  |\n| Surgical Procedure |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Pre Surgical Screening |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\n**Pre Surgical Screening (PSS) appointment to be communicated to patient by surgeon office","cbCaifjRpUAaJZYo","https://ap.wps.com/l/cbCaifjRpUAaJZYo","pdf",223255,"English","# Patient information\n## Procedure information\n## Procedure plan\n## Pre-surgical screening and confirmation","[{\"question\":\"What information is required to initiate scheduling?\",\"answer\":\"Bolded and shaded data elements are required for scheduling a surgical or endoscopic procedure, and scheduling cannot be initiated without the basic information.\"},{\"question\":\"Which pre-surgical screening options are available?\",\"answer\":\"The form lists phone call screening (typically 2–3 days prior), on-site PSS visit within 7 days (including diagnostic orders), and NP visit (Boise only).\"},{\"question\":\"What procedure and planning details must be completed?\",\"answer\":\"It requests patient type, surgery date/time request, diagnosis and procedure with ICD-10 and CPT codes, anesthesia type, estimated duration, modifiers and side selection, plus special requests, ICU bed anticipation, frozen section, and confirmation by the surgery scheduler.\"}]","Surgery Scheduling - Booking Request Form | PDF",1790375003]