8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
GENERAL 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
$%holecystectomy - &aparoscopic
&iver 'iopsy
()S
()S
*+
*+
,emmorrhoids- .lcers- /istulas- #bscesses
Pilonidal
%ystectomy
/istulectomy
()S
()S
()S
()S
*+
*+
*+
*+
,ernias
/emoral
$Inguinal 0 &aparoscopic
1entral
Incisional
.mbilical
()S
()S
()S
()S
()S
()S
*+
*+
*+
*+
*+
*+
1asectomy ()S *+
,ydrocelectomy ()S *+
%ircumcision ()S *+
'reast 'iopsy ()S *+
&ymphadenectomy- node biopsy ()S *+
Plastic
)"cision S2in &esions
Grafts- simple
Scar 3evisions
4endon 3epair
()S
()S
()S
()S
()S
*+
*+
*+
*+
*+
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
$3otation or Pedicle /laps 5minor6 ()S *+
#mputations
7inor 5/ingers- 4oes6
()S
()S
*+
*+
)ndoscopy
.pper GI )ndoscopy
%olonoscopy
%olonoscopy with biopsy
()S
()S
()S
()S
*+
*+
*+
*+
Indwelling 1enous #ccess 5Porta %ath or ,ic2man %atheter6 ()S *+
$&#S)3S
$*d8(#G laser- %+9 laser
,emorrhoidectomy
&aser #ngioplasty
()S
()S
()S
()S
*+
*+
*+
*+
3adiography .se of 7odality : interpretation of images
5therapeutic and diagnostic6
()S *+
.ltrasound .se of 7odality : interpretation of images
5therapeutic and diagnostic6
()S *+
/luoroscopy .se of 7odality with State &icense :
interpretation of images 5therapeutic and diagnostic6
()S *+
&ocal anesthesia ()S *+
%onscious Sedation ()S *+
Supervision of %onscious Sedation 4rained 3egistered
*urse
()S *+
+4,)3S *+4 &IS4);


()S *+
()S *+
()S *+
$$$DOCUMENTATION OF TRAINING AND EXPERIENCE IS REQUIRED FOR THOSE
PROCEDURES

Signature of Applicant Date
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Signature of Medical Director [Jason Snibbe,MD] Date recommended

Signature of Managing Member [Kiarash Michel, MD] Date recommended