Capital Surgery Centers Boarding Form

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Boarding & Forms
Surgeons
Media

Contact us

Home
Boarding & Forms
Surgeons
Media

Contact us

The completed form can be sent electronically by clicking on “Submit” Or the printed form can be faxed to 2485754144
Or by email info@capitalasc.com

Click Here To Download Printed Form

Physician

Todays Date

Patient Information:

Name *

Height

Weight

Address

Home

Work

Cell *

Gender

Social Security

DOB

Procedure Information:

Date of Surgery

Length (Hours)

Time

Hours

Minutes

Procedure CPT Codes

Procedure Description (as will be listed on the consent)

ICD 10 Code(s)

Diagnosis

Anesthesia

GeneralMACIV SedationLocal

Assistant

Latex Allergy

Special Requests

Additional Comments

Insurance Information:

Primary Company Name

Adjuster Name

Adjustor Phone

Claim

Date of Injury

Contact Approval or Attorney Information:

Attorney Name

Attorney Phone

Attorney Address

Pre-op Lab Work

H&PCXREKGCardiacClearanceCBCHCGUAOther

Address

2700 S. Rochester Rd.
Suite 3, Rochester Hills, MI 48307
Office: (248) 212.0777 – (248)212.0336
Fax: (248)575.4144

Open Hours

Mon-Thu: 09:00 am – 05:00 pm
Fri: 09:00 am – 02:00 pm