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:

Name*
Work Phone
Home Phone*
E-mail*

Date of Birth*

 

Name of your Physician at General Internal Medicine:

Type of Surgery:*

 

Enter the date of surgery:*

  -- mm/dd/yy

Surgeon's Name*

 

Surgery Location:*

  LRMC LGH LGH Campus Health South

Please list the lab tests requested by Surgeon's office:

Select any of the following tests that apply:

EKG
CXR
Urinalysis

Additional Comments:

Is a history and physical requested by the Surgeon?

Yes No

Most history and physical appointments are scheduled approximately 7-10 days prior to surgery unless otherwise requested by the surgeon.

Appointment preferences:

Month

Day(s)

Time of Day, you may pick more than one.

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.