Skip to content
Search for:
CI | Visotsky Surgical Request
Home
|
CI | Visotsky Surgical Request
Step
1
of
7
- Schedule Information
0%
Schedule Information
Desired Date
*
MM slash DD slash YYYY
Desired Time
:
Hours
Minutes
AM
PM
AM/PM
AM/PM/Slot
None
AM Case
PM Case
1st Case
2nd Case
3rd Case
4th Case
5th Case
6th Case
7th Case
8th Case
9th Case
Last Case
Patient Preference
None
AM Case
PM Case
1st Case
2nd Case
3rd Case
4th Case
5th Case
6th Case
7th Case
8th Case
9th Case
Last Case
Duration
*
0 Minutes
15 Minutes
30 Minutes
45 Minutes
01 Hour
75 Minutes
90 Minutes
105 Minutes
2 Hours
2 1/4 Hours
2 1/2 Hours
2 3/4 Hours
3 Hours
3 1/2 Hours
4 Hours
4 1/2 Hours
5 Hours
Hidden
Please Specify the COVID-19 Testing Site
UltraMed Skokie
CWP Libertyville
NTL
Other
Fully Vaccinated
Surgeon
*
Co-Surgeon
Assistant 2
Anesthesia Type
*
Beir Block
Choice
General
IV SEDATION
MAC
Regional Block
Straight Local
Block
None
Adductor Canal Block
Ankle
Femoral
Femoral with Catheter
Inter Scalene
Popliteal
Popliteal with Catheter
Sciatic
Sciatic with Catheter
Shoulder (BP)
Shoulder (BP) with Catheter
Single Shot Brachial Plexus Block
Notes
Next - Surgical Information
Surgical Information
Surgical Procedure
*
Side
Left
Right
BiLat
TBD
Unknown
Surgical Site
Equipment List
ACUMED /ACCUTRAK HAND
ACUMED DISTAL RADIUS
ACUMED OLECRANON
ACUMED ULNAR SHORTENING
APTUS (MEDARTIS) HAND
APTUS (MEDARTIS) DISTAL RADIUS
ANCHORS- ARTHREX Mini
ANCHORS- ARTHREX Micro
ANCHORS- Mitek Mini
ANCHORS- Mitek Micro
ARTHROSURFACE GLENOID
C-ARM
CSW TENOLYSIS KNIVES
DEPUY AP
DEPUY CTA
DEPUY FX
DEPUY GLOBAL 1
FLUOROSCAN
HAND INNOVATIONS DISTAL RADIUS
K-WIRES
MICRO INSTRUMENTS
MICROSCOPE
MODULAR HAND
OPUS LABRAL
OPUS RC REPAIR
SKELETAL DYNAMICS (SPIDER) DISTAL RADIUS
SHOULDER REVISION TRAY
SWANSON SILICON IMPLANTS (MCPJ)
SYNTHES AO MINI
SYNTHES AO SMALL
SYNTHES AO LARGE
SYNTHES LOCKING HAND
TENDON INSTRUMENTS
TRI-MED DISTAL RADIUS
TRI-MED ULNAR SHORTENING
ZOO BOX
Additional Equipment
Hidden
Brief Medical History
Hidden
Primary Care Physician
Hidden
Phone Number
Latex Allergy
*
Unknown
No
Yes
Medical Clearance
*
Unknown
No
Yes
Next - Patient Information
Patient Information
Patient Name
*
First
Last
Birth Date
*
SS# (Last 4 Digits)
*
Use 9999 if N/A
Gender
*
Male
Female
Hidden
Height
BMI
Show BMI Chart
Yes
Contact Information
Home Phone
*
Cell Phone
Work Phone
Email
*
Contact Preference
Home Phone
Cell Phone
Work Phone
I would like to upload a scan of the patients identification
Yes
You will be able to upload all files before you submit your form.
Patient Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Hidden
File Upload - Patient Identification
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 24 MB.
Both front and back must be present in the same file.
Use formats: jpg, jpeg, gif, png, pdf
Next - Primary Insurance Information
Primary Insurance Information
I would like to -
upload a scan of the insurance card
complete insurance information manually
both upload and complete insurance information manually
You will be able to upload all files before you submit your form.
Hidden
File Upload - Insurance Card
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 24 MB.
Both front and back must be present in the same file.
Use formats: jpg, jpeg, gif, png, pdf
Primary Insurance Company
*
This will assist us in identifying uploaded files.
Insurance Company Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Policy Holder
First
Last
Birth Date
MM slash DD slash YYYY
Phone Number
Policy ID
Group ID
Does the patient have secondary insurance?
*
Yes
No
Next - Secondary Insurance Information
Secondary Insurance Information
I would like to -
upload a scan of the insurance card
complete insurance information manually
both upload and complete insurance information manually
You will be able to upload all files before you submit your form.
Hidden
File Upload - Secondary Insurance Card
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 24 MB.
Both front and back must be present in the same file.
Use formats: jpg, jpeg, gif, png, pdf
Secondary Insurance Company
*
This will assist us in identifying uploaded files.
Insurance Company Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Policy Holder
First
Last
Birth Date
MM slash DD slash YYYY
Phone Number
Policy ID
Group ID
Next - CPT & ICD9/ICD10 Codes
CPT Codes
CPT1
*
CPT2
CPT3
CPT4
CPT5
CPT6
ICD10 Codes
ICD10 - 1
*
ICD10 - 2
ICD10 - 3
ICD10 - 4
ICD10 - 5
ICD10 - 6
Next - Content Submission
Content Submission
Additional Notes
The patient was provided the ISMOSC Brochure
*
Please type Yes or No
Submitted By
*
Phone Number
*
Email
*
If you have chosen to upload patient files with this request.
PLEASE ALLOW FILES TO UPLOAD. PLEASE REFRAIN FROM HITTING THE FORM SUBMISSION BUTTON MORE THAN ONCE.
Multiple File Upload (24MB) Max
Drop files here or
Select files
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 24 MB.
If uploading an ID or Insurance Card Both front and back must be present in the same file.
Use formats: jpg, jpeg, gif, png, pdf
By submitting this form I understand that all information contained withing this form is to be kept confidential.
*
Yes
Page load link
Go to Top