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Inpatient Booking Form

To be completed by medical professionals only.

    Booking Form

    Patient Details

    Admission Details

    Payment Details

    PRICE CONFIRMED WITH BOOKINGS TEAM:


    EXTRA REQUIRMENTS

    Surgical assistant required?*

    If the surgeon arranging option is selected please enter their name

    (Please note - If you are arranging a surgical assistant please ensure they are registered to work with us and have current indemnity insurance which must not be from an NHS Trust. The theatre manager should have the name of the assistant 48 hours before surgery.)

    C-ARM/X-RAY/IMAGE-INTENSIFIER NEEDED:

    Micro Air Handpiece requirement*:YESNO

    Spot Haemaglobin on admission?:YESNO

    Group and save required:YESNO

    MRSA required?:YESNO

    ECG required?:YESNO

    COVID PCR swab to be organised by Pre-assessment?:YESNO

    If patient is anticoagulated do you need it reversed for surgery:YESNO

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

    Upload any patient supporting documents

    FOR OFFICE USE:

    Completed By:

    * It is mandatory to supply this information prior to admission