Surgical Assist Scheduling Form

COMPLETE AND SEND THIS FORM BY CLICKING "SUBMIT." (*=REQUIRED)

Scheduled By:

 

Physician & Facility

 

Patient Information

  • Provide the patient's full legal name as it appears on valid ID and/or insurance card.
 

Surgery Information

 

Insurance Information

 

Physician's Authorization

  • As the operating surgeon during this procedure, I have requested Precision Assist to supply a specialized surgical assistant for me during the procedure listed above. According to the American College of Surgeons, the function of the Physician Assistant is to provide aid in exposure and hemostasis during the procedure, in addition to other technical functions that, under the surgeon's direct supervision, assist the surgeon in performing a safe operation with optimal results for the patient. Due to the complexity of this surgery, I am requiring the assistance of a Physician Assistant to provide safe, quality care, as recommended by the ACS.
 

Verification

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CONTACT US

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Fax: 210.566.1330
Email: info@precisionassist.net

OFFICE LOCATION

3502 Paesanos Parkway, Suite 101
San Antonio, Texas 78231