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GRAMERCY SURGERY CENTER INC. MAIN 212-254-3570 BOOKING 646-350-3311/3338 FAX 212-257-7004 SURGICAL BOOKING FORM SURGEON S DATE OF SURGERY PATIENT S NAME TIME ESTIMATED LENGTH Male Female WEIGHT LBS. ETHINICITY RACE DATE OF BIRTH H PHONE ADDRESS PRIMARY CARE PHYSICIAN S PCP CONTACT INFORMATION PCP S NAME TEL INS. CARRIER SUBSCRIBER S NAME INS. ID SECONDARY INS. CARRIER PRECERT PROCEDURE DESCRIPTION CPT CODE DIAGNOSIS W/ CODE ANESTHESIA TYPE PLEASE CHOOSE ONE General ANTIBIOTICS TO BE...
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