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:
- PATIENT’S FIRST name
- PATIENT’S MIDDLE INITIAL ( OR NAME) -- When applicable & listed on I.D. – This is an added field.
- PATIENT’S LAST name
- Please be sure that fields on the form are entered directly from the I.D. as shown, which is used for patient labels/charts.
*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...
Make selection then click cursor into Patient's Birth Date Field.
Make selection then click cursor into Patient's Status Field.
Primary Insurance Information
Secondary Insurance Information
*If no Secondary Insurance applicable and/or Worker's Compensation, click cursor into Scheduler Name Field.
Worker's Compensation Information (if applicable)
Questions? Please call Surgery Scheduling at (714) 961-5935. Thank you!
**Save as PDF and Print feature only works with Google Chrome.
*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.