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Surgery Department Online Scheduling

Welcome to Lakewood Regional Medical Center centralized online surgery scheduling form.

*Important: – Please go to “Internet Options” on your browser and clear your “Cache” and “cookies” so updates to the form will appear.

*“Save as PDF and Print” currently only works on Google Chrome. To use this function, please download Google Chrome and complete your forms in that browser. Please also Save as PDF and Print prior to hitting submit. Thank you.

*If you would like a printed copy, please hit “Print a Copy*” prior to hitting the Submit button. Thank you.

Clear Form
Select a choice *

Patient Information

SEX *

Surgery Information

First Assist/PA *
Patient Status *
23 Hour Hold *
Make selection then click cursor into Procedure Field.
Special Equipment: Fluoroscopy *
Anesthesia Type *

Primary Insurance Information

If you selected other for primary relationship please enter the relationship here

Primary Type # *

Secondary Insurance Information

If you selected other for primary relationship please enter the relationship here

Primary Type
*If no Secondary Insurance applicable and/or Worker's Compensation, click cursor into Scheduler Name Field.

Worker's Compensation Information (if applicable) 

Scheduling Information

999-999-9999

999-999-9999

Questions? Please call Surgery Scheduling at (562) 602-6746

Upload Files

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Click here to Print a Copy

**Save as PDF and Print feature only works with Google Chrome.