Preoperative Appointment Request


This form is for patients requesting non-urgent appointments only. If you require an immediate appointment please call the preadmission testing department at General Internal Medicine (717) 397-2738 Ext. 148.

* Required Fields

Name: *
Date of Birth: *
Work Phone:
Home Phone:
Email: *
 
Name of your Provider:
 

Surgery Information:

Surgery Type: *
Surgery Date: *
Surgeon's Name: *
Surgery Location: *
Please list the lab tests requested by the Surgeon:
Select any of the following tests that apply: EKG
CXR
Urinalysis
Is a history and physical requested? Yes
No
Additional Surgical Comments:
 

Appointment Preferences:


Most history and physical appointments are scheduled approximately 7-10 days prior to surgery unless otherwise requested by the surgeon.
Month:
Day(s):
Time: AM
PM
Evening
 
Questions/Comments:
Verification Code:*
Please input the numbers you see into the box below.
No spaces are necessary.
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You will be notified by e-mail of your appointment approximately 48 hours after we receive your request. For weekends allow at least 72 hours. Thank you for using our website.


General Internal Medicine of Lancaster

2301 Columbia Avenue • Lancaster, PA 17603 • Phone: (717) 397-2738 • Fax: (717) 397-7634

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