Orthopedic Advanced 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 orthopedic surgery average daily censusAnnual Emergency Department volumeDraw areaCurrent EMR/EHRLevel of trauma designation (if applicable)Orthopedic 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 consultsEstimated number of orthopedic admissions last yearNumber of and case mix of orthopedic procedures performed last yearSurgeon requirements/skillsHip and knee arthroplasty Yes No Basic hand (trigger finger, carpal tunnel, etc.) Yes No Pediatric (Age Range) Yes No Sports Yes No Fracture care/trauma Yes No OtherCurrent availability of orthopedic surgery surgical block timeAvailability of outpatient/follow-up clinic space and staff for program useCurrent implant vendor(s)
