Urology 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 urology surgery average daily censusAnnual Emergency Department volumeDraw areaCurrent EMR/EHRLevel of trauma designation (if applicable)General Urology Program OverviewCoverage Required - Acute Care (ED Call, inpatient consults), elective practice, etc.Urology ClinicOffice procedures (vasectomies, cystoscopies, prostate biopsies, etc)Anticipated annual surgical volume of elective practiceEmergency Department - estimated number of urologic consultsInpatient - estimated number of uroligic consultsNumber of and case mix of urologic procedures performed last yearSurgeon requirements/skillsEndoscopyCystoscopy, ureteroscopy, laser lithotripsy, transurethral resection Yes No Scrotal surgery (hydrocele, spermatocele, vasectomy, varicocele, orchiectomy, abscess, testicluar torsion, etc); penile prosthesis Yes No Laparoscopy or robotic surgery (prostatectomy, nephrectomy) Yes No Open abdominal / pelvic surgery (ureteral injury, reimplant) Yes No Female Urology Yes No OtherCurrent availability of urology surgical block timeAvailability of outpatient/follow-up clinic space and staff for program usePresence of primary care clinic for referrals / multispecialty clinics
