8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Name
_______________________________________
OB/GYN SURGERY PRIVILEGES
I hereby request surgical privileges in the specialty of General Surgery as shown
in this form. I understand that privileges granted are subject to a bi-annual
review coinciding with reapplication for medical staff membership. I also
understand that application for additional or new procedures can be made at any
time with proper documentation.
Please indicate with an ! in the appropriate bo" and by signature at the end of
this document the procedures you are requesting privileges for.
#pplied for #pproved
$valuation and diagnosis of medical conditions to
determine need for surgical intervention with regard to
appropriate consultation when prudence and good medical care
require so.
%$S &'
(( )ysteroscopy %$S &'
(($ndometrial ablation- electrosurgical %$S &'
((GI*+ %$S &'
((,aser-intra-abdominal %$S &'
((,aser-laparoscopy %$S &'
((,aser-lower genital %$S &'
((-emoval of condyloma .laser/ %$S &'
#nterior colporrhaphy
Posterior colporrhaphy
%$S
%$S
&'
&'
0artholin gland1 e"cision or maruspiali2ation %$S &'
0iopsy3 vulva1 cervi"1 vagina %$S &'
4autheri2ation vaginal cyst %$S &'
4ervical coni2ation %$S &'
564-diagnostic %$S &'
564-therapeutic %$S &'
$"am under anesthesia %$S &'
*oreign body removal from vagina %$S &'
)ymeotomy %$S &'
#55$5 7897:987
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Name
_______________________________________
I;5 removal %$S &'
I<* %$S &'
,aparoscopy-pelviscopy %$S &'
,aparoscopy-tubal ligation %$S &'
,aparotomy-limited9mini %$S &'
,ysis of adhesions of the clitoris %$S &'
=yomectomy .intrauterine/ %$S &'
Perineoplasty-simple %$S &'
Perineorrhaphy %$S &'
Polypectomy-cervical or uterine %$S &'
-emoval of adne"al-partial9complete %$S &'
-emoval of condyloma .surgical/ %$S &'
-epair surgical rent-bladder1bowel %$S &'
Simple e"cision of s>in lesion %es &'
<aginal stenosis release
<ulvar or labial biopsy %$S &'
(( ray interpratation %$S &'
((,#S$-S
(&d3%#G laser1 4'? laser %$S &'
-adiography ;se of =odality 6 interpretation of images
.therapeutic and diagnostic/
%$S &'
;ltrasound ;se of =odality 6 interpretation of images
.therapeutic and diagnostic/
%$S &'
*luoroscopy ;se of =odality with State ,icense 6
interpretation of images .therapeutic and diagnostic/
%$S &'
,ocal anesthesia %$S &'
4onscious Sedation %$S &'
Supervision of 4onscious Sedation +rained -egistered
&urse
%$S &'
'+)$-S &'+ ,IS+$5
%$S &'
%$S &'
#55$5 7897:987
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Name
_______________________________________
%$S &'
(( DOCUMENTATION OF TRAINING AND EXPERIENCE IS REQUIRED FOR THOSE
PROCEDURES

Signature of #pplicant 5ate

Signature of @I committee chairperson 5ate recommended

Signature of Governing 0ody chairperson 5ate recommended
#55$5 7897:987