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Theatre booking form

This form is for medical professionals only.

Weymouth Street Hospital

Phoenix Hospital Chelmsford

Title*

First Name*

Last Name*

Gender*

Date of Birth*

Phone Number*

Email*

Residential address*

Postcode*

NHS Number*

Surgeon / Consultant*

Anaesthetist (Leave blank if unknown)

Date of admission*

Time of admission - needs to be confirmed by WSH

Date of procedure*

Time of procedure*

Procedure(s)*

Procedure code

Estimated operation length (including anaesthetic time)*

Anaesthesia type*

Length of stay*

No. of nights*

Payment type*

Price confirmed with bookings team?*

Yes

Hospital fee amount (please give breakdown)

Name of your Insurer

Membership no.

Authorisation code

Embassy (required if Embassy is selected)

Letter of guarantee?*

Yes

Is the patient anticoagulated? (Please advise the patient if the Consultant requires the medication to be ceased prior to surgery)*

Yes

Blood test or investigation required at Pre-assessment? e.g ECG or FBC

Histology

Physiotherapy*

Dietary / Allergies

Wheelchair Access

C-arm/X-ray/Image-intensifier needed?*

Yes

Micro Air Handpiece requirement?*

Yes

Equipment requirements*

Laser requirements*

Surgical assistant required from theatre?

Prosthesis / Implants(s) requirements. i.e. Mirena Coil, Earfold

Spot Haemoglobin on admission?*

Yes

Group and Save required on admission – Only required for high risk of bleeding procedures*

Yes

Cross match required? (Please state number of units)

Have you attached details of patients past medical and medication history?*

Yes

Please upload any patient supporting documents:

Please provide a MDT summary with clinical information

INS / FEE

Full name*

Email address*

Phone Number*

Date*