Surgical Posting Request Form

For all scheduling beyond 72 hours, please complete the online form and submit.

If the posting is for within 72 hours or if you need to reschedule or cancel an already scheduled case please call the Scheduling Department at 443-849-6700.

* Indicates required information
Submitted By/Contact Person * 
Phone Number * 
Senders E-mail Address * 
Date Requested *  Calendar (mm/dd/yyyy)
Time Requested * 
Site * 
Surgeon 1 * 
Surgeon 2 
Assistant * 
PCP Name * 
PCP Phone Number * 
GBMC Pat Appt * 
Informed Consent * 

Last name * 
First name * 
Date of Birth * 
Home Phone * 
Work Phone 
Gender * 

Bariatric Patient 
Pacemaker * 
Allergic to Latex * 
Allergic to Penicilin * 
If allergic to penicilin, what is the reaction 
Address Street * 
City * 
State * 
Zip * 
Primary Insurance * 
Primary Policy * 
Subscriber * 
Primary Group * 
Secondary Insurance 
Secondary Policy 
Secondary Group 
Anesthesia * 
Block type 
Patient Type * 
Cosmetic Only 
Post OP Destination * 
If no Length of Stay (LOS) enter N/A 
LOS (Primary) * 
LOS (Secondary) 
Blood Ordered 
Blood Type 
Blood Units 
Films Required 
IOM Required 
Diagnosis * 
Surgical Site * 
For Procedure Number 1, fill in '0000-Unknown Number' if you do not have the number. 
Procedure Number 1 * 
Actual Procedure Details * 
Procedure Number 2 
Actual Procedure Details 
Procedure Number 3 
Actual Procedure Details 
Type in N/A if there is no special equipment. 
Special Equipment * 
Clinical Trials 
Greater Baltimore Medical Center | 6701 North Charles Street | Baltimore, MD 21204 | (443) 849-2000 | TTY (800) 735-2258
© 2016  GBMC. This website is for informational purposes only and not intended as medical advice or a substitute for a consultation with a professional healthcare provider.