Spine Procedure Scheduling Form

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HOSPITAL
FOR
SPECIAL
SURGERY
Spine Procedure Scheduling Form
Please ask the patient to bring any outside films with them
Referring office must communicate appointment time to patient
Patient name: ___________________________
MRN: _____________ Phone: ___________________
Referring MD: ___________________________
Phone: ____________ Fax:
___________________
Is the patient anticoagulated?
No
Yes
Is there any h/o contrast reaction?
No
Yes
Prior back surgery?
No
Yes
(____) Myelogram
Cervical
Thoracic
Lumbar
(____) Nonselective Lumbar Epidural Injection
(indicate level, if appropriate)
(____) Sacroiliac Joint Injection (Choose side)
right
left
(____) Discogram
(select levels)
T12-L1 L1-2 L2-3
L3-4
L4-5
L5-S1
(____) Selective Nerve Root w/ Steroid Injection
(1 cervical or 2 lumbar sites per visit)
Site #1
Side (circle one):
right
left
Select nerve (eg. C5, L4, S1)
Site #2
Side (circle one):
right
left
Select nerve (C5, L4, and S1)
(_____) Facet Block w/Steroid Injection (2 sites per visit)
Site #1:
Side (circle one):
right
left
Select level (e.g. C4-5, L4-5):
Site #2
Side (circle one):
right
left
Select level (e.g. C4-5, L4-5)
The patient should report to Radiology reception on the 3
floor
rd
Date: ____________________________
Time: ________________
CONFIRMATION: NAME:
DATE:
BY: PHONE
FAX:
535 East 70th Street, New York, NY 10021 Tel. 212-606-1258 Fax. 212-737-0946
(07/2013/TL)

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