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 casesplease 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...


mm/dd/yyyy
mm/dd/yyyy

Patient Information

("Patient's Last Name" must be entered exactly as it appears on the driver's license/government issued i.d. Entering it incorrectly will delay the patient's surgery).
("Patient's First Name" must be entered exactly as it appears on the driver's license/government issued i.d. Entering it incorrectly will delay the patient's surgery).
("Patient's M.I./Name" Must be entered when shown on I.D. exactly as shown).
Patient's Gender *
Make selection then click cursor into Patient's Birth Date Field.
mm/dd/yyyy
999-99-9999
999-999-9999
999-999-9999

Surgery Information

RNFA *
Make selection then click cursor into Patient's Status Field.
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

Secondary Insurance Information

If you selected other for primary relationship please enter the relationship here
If you selected other for secondary relationship please enter the relationship here
mm/dd/yyyy
mm/dd/yyyy
Primary Type # *


Secondary Type #


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

Worker's Compensation Information (if applicable)

999-999-9999
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.

*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.