New procedure or treatment request form

This form is easy to follow and has the required questions. Consider pairing it with a policy and procedure to guide its use and including a section to denote confirmation of the hospital’s assessment/ability to perform a new procedure or treatment, the need for new equipment, etc.  

Reviewed by CRC's Tools and Forms Committee: 02/18
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Related Content: 

Introducing new procedures and technologies
Responding to privileging requests involving new procedures
New technology request form