Accessibility Statement

We are committed to providing a website that is accessible to the widest possible audience. To do so, we are actively working with consultants to update the website by increasing its accessibility and usability by persons who use assistive technologies such as automated tools, keyboard-only navigation, and screen readers.

We are working to have the website conform to the relevant standards of the Section 508 Web Accessibility Standards developed by the United States Access Board, as well as the World Wide Web Consortium's (W3C) Web Content Accessibility Guidelines 2.1. These standards and guidelines explain how to make web content more accessible for people with disabilities. We believe that conformance with these standards and guidelines will help make the website more user friendly for all people.

Our efforts are ongoing. While we strive to have the website adhere to these guidelines and standards, it is not always possible to do so in all areas of the website. If, at any time, you have specific questions or concerns about the accessibility of any particular webpage, please contact so that we may be of assistance.

Thank you. We hope you enjoy using our website.

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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:

  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.



Select a choice

Patient Information

Patient's Gender *

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




Surgery Information

Patient's Status *

Make selection then click cursor into Procedure Field.
Special Equipment: Fluoroscopy *
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


Primary Type # *

Secondary Insurance Information

If you selected other for secondary 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



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

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