Surgery Scheduling Form

Sutter Medical Center, Sacramento

Note: Required fields marked with *

Surgery Scheduling Information

Facility Phone Fax
Capitol Pavilion (CP) (916) 262-9485 (916) 503-7680
SGH (916) 733-1052 (916) 503-7667
SMH (916) 733-1052 (916) 503-7668
If you do not wish to submit this form online, Download this form and fax it to us.

Surgery Site Information
*
   

Surgery Information

AM IP
Day Before
OP

Patient Information
*
*
Male
Female
*

Yes No
*


(if different from above):
   
*
*
*
*
* We require a home phone and one alternate contact number.

Insurance Information