Pain Consultants of the Rockies, PC
and Pain Treatment Center of Wyoming, LLC

903A South Greeley Highway, Cheyenne, WY  82007
307-633-8100  Fax: 307-633-8108 

Surgery Scheduling Sheet

Today’s Date:_______/_______/________                Scheduler:_______________________

Patient Name:______________________________________________________________

DOB: _______/_______/_______                                SSN: ________/_______/_________

Phone: Home: (         ) ______-__________                  Other: (        )______-____________

Procedure:________________________________________________________________

RT   LT   BILAT   CPT: __________________     ICD-9:__________________

Procedure Date:_______/_______/_______

Time:________am/pm      Amt Time Needed: __________

AUTHORIZATION

Primary Insurance:___________________________  Policy/Case ______________________

Phone Number: (         ) ______-__________

Secondary Insurance:_________________________ Policy/Case ______________________

Phone Number: (         ) ______-__________

NOTES:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Authorization Date: _______/_______/________

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