Booking Forms

NOTE: Please confirm the availability with us before submitting online booking requests.

4 Easy Steps to Book Cases Online:

  • Scroll down to “Online Forms” on this webpage.
  • Click “+” on the specialty you choose to book. (All specialties, except Urology, Podiatry, ENT, and Pain Management, should use General Form.)
  • Complete the form and click “Submit.”
  • Fax a clear copy of the insurance card to 866.249.5146.

For your convenience, PDF versions of the Booking Forms are also available for download at the bottom of this page. Once filled, please fax a clear copy of the insurance card together with the booking form to 866.249.5146.

Questions on booking cases? Contact us at 212.254.3570 Option #2, 8AM – 6 PM ET, Monday to Friday.


Online Forms

General Form
  • Date Format: MM slash DD slash YYYY


  • Patient Information

  • Date Format: MM slash DD slash YYYY


  • Primary Care Physician (PCP) Contact Information


  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY


  • Procedure Information

  • Date Format: MM slash DD slash YYYY



  • Please make sure this form is filled in completely.
    Please fax insurance card to 866.249.5146.

    *Booking FORM is due ONE WEEK in advance*

Urology Form


  • Patient Information


  • Primary Care Physician (PCP) Contact Information


  • Insurance Information




  • Please make sure this form is filled in completely.
    Please fax a copy of the front and back of the insurance card to 866.249.5146.

    *Booking FORM is due ONE WEEK in advance*

Podiatry Form
  • Date Format: MM slash DD slash YYYY


  • Patient Information

  • Date Format: MM slash DD slash YYYY


  • Primary Care Physician (PCP) Contact Information


  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY


  • Procedure Information


  • Supplies/Equipment

  • Date Format: MM slash DD slash YYYY



  • Please make sure this form is filled in completely.
    Please fax insurance card to 866.249.5146.

    *Booking FORM is due ONE WEEK in advance*

ENT Form


  • Patient Information


  • Primary Care Physician (PCP) Contact Information


  • Insurance Information




  • Please make sure this form is filled in completely.
    Please fax a copy of the front and back of the insurance card to 866.249.5146.

    *Booking FORM is due ONE WEEK in advance*

Pain Management Form


  • Patient Information


  • Primary Care Physician (PCP) Contact Information


  • Insurance Information


  • Procedure Information



  • Please make sure this form is filled in completely.
    Please fax insurance card to 866.249.5146.

    *Booking FORM is due ONE WEEK in advance*

Ophthalmology


  • Patient Information


  • Insurance Information

  •  

General
(PDF)
Urology
(PDF)
Podiatry
(PDF)
ENT
(PDF)
Pain Management
(PDF)
Ophthalmology
(PDF)

Scheduling Inquiries

    Please fill out the form below and submit it. A scheduling representative from Gramercy Surgery Center will get back to you as soon as possible.

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