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Hematologic Eval for Surgery/Procedure

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Anticoagulation evaluation for Surgery/Procedure requests will be processed as soon as possible. In order to speak with a team member, please call 1.317.871.0000 between the hours of 8 am–5 pm, Monday through Friday. Please provide the following information:

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Patient Information

First Name :

Last Name :

Date of Birth :

Surgery/Procedure Information

Surgery/Procedure :

Surgery/Procedure Date :

Surgery/Procedure Date TBD :

Yes

Outpatient :

Yes

Inpatient :

Yes

If Inpatient, anticipated length of stay :

Surgery/Procedure Facility Location :

Surgeon Last Name :

First Name

Phone :

Fax :

Comments :

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