Microsoft Word AM ADMIT FORM

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1 DOCTORS COMMUNITY HOSPITAL SURG ICAL AM ADMIT CONFIRMATION tient for surgery at DCH with th e request to ha ve the patient You have scheduled the following pa admitted. For compliance reasons, we are required to have a signed confirmation of the AM and if any changes need to be made to your Admit order. Please review the information below case contact Surgical Posting at 301-552-0400. If a ll information is correct, please sign and fax this form to 301-552-8528 at least 48 busin ess hours prior to date of surgery. Surgeon: ________________________________ Surgery Date: ________________________ Pt's Name: _________________________________________ Pt's DOB: __________________ Diagnosis: Procedure: Patient Admit Type: AM INPATIENT ADMISSION ______________________ _________________ ______________________ _________________ Surgeons Signature ID# Surgeon Name Printed Date/Time

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