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 397-2738 Ext. 148.

* Required Field

Please provide the following contact information:

Your Information

Name*
Date of Birth*
Work Phone
Home Phone*
Email*
GIM 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


Comments



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 web site.


   


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2301 Columbia Avenue Lancaster, PA 17603
Phone - 717.397.2738 Fax - 717.397.7634

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