Great Lakes Surgical Center
Scheduling/Boarding Form
Name: *
Your answer
Date of Birth: *
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DD
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YYYY
Sex:
Home Phone: *
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Work Phone:
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Alt Phone:
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Street Address:
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City
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State:
Zip Code:
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Email Address:
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Date of Surgery: *
MM
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DD
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YYYY
Length: *
Your answer
Anesthesia: *
Your answer
Surgeon: *
Your answer
Procedure: *
Your answer
CPT Code:
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ICD10:
Your answer
Special Equipment:
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Cosmetic Procedure:
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Workman's Comp:
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Date of Injury:
MM
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DD
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YYYY
Claim:
Your answer
Claim Adjuster:
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Authorization:
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Primary Insurance Name:
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Primary Insurance Subscriber:
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Primary Insurance Relationship to Patient: *
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Primary Insurance Date of Birth: *
MM
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DD
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YYYY
Primary Insurance Policy:
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Primary Insurance Group:
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Secondary Insurance Name:
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Secondary Insurance Subscriber:
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Secondary Insurance Relationship to Patient:
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Secondary Insurance Date of Birth:
MM
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DD
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YYYY
Secondary Insurance Policy:
Your answer
Secondary Insurance Group:
Your answer
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