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Physician Offices Norfolk NE

Scheduling Form

  • Must be faxed same day as case is scheduled
  • Must be complete
  • Surgery officially scheduled and consent based on how the procedure is written on this form – please confirm with surgeon to avoid errors in preparation or on the day of surgery
  • Do not send patients over to facility for pre-registration type activities
  • Office may inform the patient as to what time they are tentatively scheduled but remind patient that this is subject to change. SurgiCenter will give the arrival time during the pre-op call

Surgeon’s office should instruct patient when/if the patient should discontinue any medications that affect the procedure (NSAIDS, blood thinners, etc.). SurgiCenter of Norfolk will instruct patients regarding all other medication to hold or take on the day of surgery.

H&P’s may be completed up to 30 days prior to surgical date. Please schedule these appointments so that all information can be RECEIVED by SurgiCenter of Norfolk at least 5 days prior to the surgical date. Also, please send the H&P, lab reports, etc. as soon as they are complete rather than holding them for any reason. The sooner the SurgiCenter receives this information, the better, so we can review their histories and try to prevent last minute delays or cancellations.

Please complete the blanks on the front of the SurgiCenter of Norfolk Patient Brochure and send this with the patient at the time of scheduling. If the procedure is scheduled without the patient being physically present, please send the completed brochure via mail to them.

SurgiCenter of Norfolk Patient Selection Criteria

Age Restrictions

  • No Tonsillectomy < age 3
  • No Adenoidectomy < age 2 (age 2-3 only with high degree of evaluation of respiratory status including runny nose, cough and fever)
  • No Myringotomy Tube Placement < 9 months
  • Other surgical patients less than 2 years of age at discretion of Anesthesia provider (consideration given to type of procedure, health status and medical history)

Automatic Exclusion Criteria

  • BMI > 48 (with discretion of Anesthesia)
  • Asthma/COPD hospitalization within 1 year
  • Oxygen use
  • EF < 40%
  • Congenital Heart Disease
  • Uncontrolled hypertension (SBP>180 or DBP>100)
  • Pacemaker/AICD
  • Neurologic disease (ie: Parkinson’s, MS)
  • Significant bleeding disorder
  • History of difficult airway, head/neck radiation, or history of tracheostomy
  • Personal or family history of Malignant Hyperthermia
  • Diabetic patients receiving steroid injections with blood glucose greater than 180 mg/dL or all other diabetic patients with blood glucose greater than 220 mg/dL; these patients will be referred to their PCP for diabetic management and rescheduled thereafter.    
  • Dialysis patients (with discretion of anesthesia)
  • Patients with significant fever, wheezing, nasal congestion, and cough as symptoms of a recent upper respiratory tract or sinus infection.

Must be approved by Anesthesia provider:

  • Sleep apnea


  • Oncology patient with no systemic impairment
  • H/o MI, CABG, stent – OK for SurgiCenter of Norfolk if event > 6 months ago and patient seen by cardiology within last 6 months with no cardiac symptoms    

If you would like to schedule a patient at SurgiCenter of Norfolk but are unsure if they are a candidate, please call and speak with an Anesthesia provider.

Pre-Admission Testing Guidelines

Pre-operative laboratory testing should be based on the planned procedure, and the history and physical. The following guidelines are not intended to replace the clinical judgment of the physician. Some patients will require additional workup. If you have any questions about a particular patient, please discuss these with an anesthesiologist.

Test/Eval & Considerations For Performing

HCT or HGB    

History of anemia, potential significant blood loss
Valid within 1 month


History of cardiocirculatory disease or recent signs/symptoms
Valid within 6 months

Serum Chemistry    

History of renal disease
Valid within one week

Serum Potassium

Taking digoxin, diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers.
Valid within 24 hours of procedure

Coagulation Studies    

Required for patients taking anticoagulants
Valid within one week (if unstable, 24 hours)

Chest X-Ray    

History of CHF, cardiocirculatory disease, or recent URI
Valid within 1 year unless recent symptoms


If symptomatic of UTI