CFS 431: Medical/Surgical Treatment Request
Please read the instructions below prior to completing the request. Failure to follow instructions may result in a processing delay.
Instructions:
Medical/ Surgical requests must be completed by a medical professional and can be submitted up to 30 days before the procedure date. If you have your own internal consent form needing review, please include it as an attachment with your submission.
Please be aware of the following when completing the form:
1. Do not use acronyms anywhere in the request.
2. If you are requesting blood, you must select "Administration of Blood" even if only for emergency purposes.
3. Do not write "see attached" or "not applicable" for the Statement of Patient's General Health.
4. Please specify the specific tooth/teeth affected for dental requests.
5. You must include the full name and address of the doctor(s) AND the hospital/clinic where the procedure will take place.
This type of request for consent is NOT valid for the following items. Please call the consent unit hotline Monday - Friday from 8:30am - 4:30pm at (800) 828-2179. For after hours / state holidays, call (866) 503-0184:
1. Emergency room
2. Urgent care, prompt care, express care, immediate care
3. Walk in clinic
