Patient:
Date of Operation:
Primary Surgeon:
Attending Surgeon:
Surgical Specialty:
Principal Operative Procedure:
Principal Preoperative Diagnosis:
Laterality Of Procedure:
Planned Admission Status:
Planned Principal Procedure Code:
Demo ICD-10 Procedure Code:
Hospital Admission Status:
Major or Minor:
Case Schedule Type:
Palliation:
Planned Postop Care:
Requested Anesthesia Technique:
Intraoperative X-Rays (Y/N/C):
REFERRING PHYSICIAN: