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Surgery Booking Form

MultiCare A

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SURGERY BOOKING FORM
Date of Surgery
MM slash DD slash YYYY
Requested Time
Length
Provider*
First
ICD 10s
Procedure
Special Equipment/Implants
Patient Demographics (COMPLETE OR ATTACH DEMOGRAPHIC PROFILE)
Name*
First Name Last Name
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
EPIC MRN
Address*
Street Address Address Line 2 City State ZIP Code
Phone number (primary)*
Alternate Phone*
Parent/Guardian Name (if a minor)
First
Interpreter required?*
- Yes
- No
Language*

Medical conditions:
BMI
Taking blood thinners
Taking blood thinners
Medical conditions:
- Diabetes
- Heart disease/previous MI
- Stroke
- HTN
- Sleep apnea
- Kidney disease

Medical Insurance/Authorization
Insurance
- Commercial
- Workers Comp (also include private ins info)
- Medicaid
- Self Pay
*** Please attach a copy of authorization and commercial medical insurance card(s) (front & back) ***
Drop files here or

Accepted file types: jpg, docx, png, pdf, Max. file size: 25 MB.
Insurance Name (Primary)
First
Policy Number
Subscriber
DOB
MM slash DD slash YYYY
Benefits Phone #
Pre Auth #
Authorization required?
- Yes
- No
Authorization #
Exp. Date
MM slash DD slash YYYY
***Anesthesia: Contact Stephanie with Rainier Anesthesia @ 800-394-4445 Ext 2913 ***

1002 15th STREET SW, SUITE 215, AUBURN, WASHINGTON 98001 PHONE (253) 736-6600 FAX (253)288-2219
Email
This field is for validation purposes and should be left unchanged.

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Company Information

MultiCare Cascade Surgical Center

1002 15th Street SW, Suite 215
Auburn, WA 98001
Phone: 253-736-6600

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About Us
- Mission and Vision
- Location
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Patient Info
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Contact Us
Employee Portal
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