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Surgery Department On-line Scheduling 

Welcome to Placentia-Linda Hospital's centralized on-line surgery scheduling form.

The fields in (*) are required fields and cannot be left blank. Please complete and then hit submit.

Online Form Notifications/Enhancements*:

(*For PLH Admin Use Only)

To help avoid delays in surgery cases, please verify you enter information EXACTLY AS SHOWN on the patient’s driver’s license or government issued i.d. for:

  1. PATIENT’S FIRST name
  2. PATIENT’S MIDDLE INITIAL ( or name) - When applicable & listed on I.D. - This is an added field.
  3. PATIENT’S LAST name
  4. Please be sure that fields on the form are entered directly from the I.D. as shown, which is used for patient labels/charts.

Thank you!

*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.

Online Form Notifications/Enhancements….”From feedback, revisions have been made as of (02/22/2016) date.

mm/dd/yyyy

mm/dd/yyyy

Select a choice

Patient Information

Patient's Gender *

Make selection then click cursor into Patient's Birth Date Field.

mm/dd/yyyy

999-999-9999

999-999-9999

Surgery Information

RNFA *
Patient's Status *

Make selection then click cursor into Procedure Field.
Anesthesia Type *

Make selection then click cursor into Length of Time Needed Field.

Primary Insurance Information

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

mm/dd/yyyy

Primary Type # *

Secondary Insurance Information

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

mm/dd/yyyy

Primary Type

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

Worker's Compensation Information (if applicable) 

mm/dd/yyyy

Scheduling Information

999-999-9999

999-999-9999


Questions? Please call Surgery Scheduling at (714) 961-5935. Thank you!

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