40 stetson Surgery Scheduling - Ankle Medical Form - Oct. 20, 2024, 10:21 p.m.

Surgery Scheduling
Surgeon • • •
Location • • •
Surgical Site • • •
Diagnosis and ICD 10 Code
Surgical Procedure • • •	Additional Surgical Procedures
Pre-operative Clearance?
Length of Surgery	Type of Anesthesia • • •
Position • • •	Assist • • •
Special Equipment

Surgery Scheduling
Surgeon • • •	Location • • •
Surgical Site • • •
Diagnosis and ICD 10 Code
Surgical Procedure • • •	Additional Surgical Procedures
Pre-operative Clearance?	Length of Surgery
Type of Anesthesia • • •	Position • • •
Assist • • •	Special Equipment

Patient Information

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Published: Oct. 20, 2024, 10:21 p.m.
Doctor: Dr. History Physical
Rating: 0 /

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