Children's Healthcare of Atlanta Surgery Scheduling Form

Children's Healthcare of Atlanta Surgery Scheduling Form
Date of procedure*

MonthDayYear
Date
Locations*
Patient Information
Legal Name*

First NameMiddle NameLast Name
Preferred Name (Nickname)
Date of Birth*

MonthDayYear
Date
Gender*
Email (If patient is 18 years or older, please provide their email).
example@example.com
Has this patient ever been to a Children's facility before?
Has their name changed?
What name has the patient previously used?
Does this patient need an interpreter?
If so, what language?
Guardian Information
IMPORTANT: A medical history form will be sent to the guardian through MyChart prior to patient's procedure. Complete information for Guardian #1 is required for the form link to be sent.
Guardian #1 Name*

First NameLast Name
Guardian #1 Mobile Phone Number*
Please enter a valid phone number.
Guardian #1 Home Phone Number
Please enter a valid phone number.
Guardian #1 Email Address*
example@example.com
Guardian #1 Date of Birth*

MonthDayYear
Date
Relationship to Child*
Other (please specify):
Guardian #1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian #2 Name

First NameLast Name
Relationship to Child
Other (please specify):
Emergency Contact

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.
DFAC/Social Worker's Name

First NameLast Name
DFAC/Social Worker Phone
Please enter a valid phone number.

CPT Code(s)*
Diagnosis*
ICD 10 Codes*
Comments and Equipment
Tissues Needed
Admitting Physician

First NameLast Name
Primary Care Physician Name

First NameLast Name
Pre-op Antibiotics?*
Preferred Drug
Insurance Information
Guarantor's Legal Name*

First NameLast Name
Relationship*
Other (please specify):
Guarantor's Date of Birth*

MonthDayYear
Date
Medicaid Patient?*
For Medicaid patients, please include parent's name and date of birth (if different from guarantor listed above)

Employer
Primary Insurance*
Product
Authorization number
Member ID#*
Group #*
Pre-Cert Phone #
Please enter a valid phone number.
Authorization status
If authorization is required and not obtained at least 48 hours prior to the date of surgery, the patient is at risk of being rescheduled.
Authorization Number
Is there another/secondary insurance?
Secondary Insurance*
Employer
Guarantor's Legal Name*

First NameLast Name
Guarantor's Date of Birth*

MonthDayYear
Date
Relationship*
Other (please specify):
Product
Member ID#*
Group #*
Pre-Cert Phone #
Please enter a valid phone number.
Authorization Status
If authorization is required and not obtained at least 48 hours prior to the date of surgery, the patient is at risk of being rescheduled.
Office Contact Name*
Office Email Address*
example@example.com
Office Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Should be Empty:

Patient Information