General Surgery Form Begin this form and start the process of connecting with Synergy Health Partners. Submit Now Hospital InformationHospital NameCityStateHospital Primary Contact(Required) First Last TitlePhoneEmail Program Goals & DriversPlease briefly describe your situation and the challenges and problems you are trying to address (call coverage gaps, elective case backlog, decrease outmigration, trauma support, increase revenue, etc)?Hospital OverviewTotal hospital bedsOverall and general surgery average daily censusAnnual Emergency Department volumeDraw areaCurrent EMR/EHRLevel of trauma designation (if applicable)General Surgery Program OverviewNumber of surgeons currently providing coverageCoverage Required - Acute Care (ED Call, inpatient consults), elective practice, etc.Anticipated annual surgical volume of elective practice (if applicable)Emergency Department - Estimated number of monthly surgical consultsInpatient - Estimated number of monthly surgical consultsNumber of and case mix of general surgery procedures performed last yearSurgeon requirements/skillsEndoscopyUpper Yes No Lower Yes No Interventional Yes No Screening Yes No Wound care Yes No Podiatry (diabetic foot) Yes No Venous access Yes No OtherCurrent availability of general surgery surgical block timeAvailability of outpatient/follow-up clinic space and staff for program use
