8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
OPHTHALMOLOGY SURGERY
I hereby request surgical privileges in the specialty of Ophthalmology 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 X in the appropriate bo! and by signature at the end of
this document the procedures you are requesting privileges for.
Applied for APPROVED DENIED
"#$#%#&'I(#% $)$*+(,
-acryocystorhinostomy and conjunctivo-
dacryocystorhinostomy
'epair canalicular system and nasalocrimal duct
)+$
)+$
"O
"O
+)+%I-$ . +)+/'O0$
'emoval of tumors
Ptosis correction
/lepharoplasty
)+$
)+$
)+$
"O
"O
"O
+X*'#O&1%#' (1$&%+$
$trabismus surgery )+$ "O
2%O/+
+nucleation and evisceration )+$ "O
Pterygium removal or transplantation )+$ "O
&onjunctival procedures )+$ "O
'epair trauma )+$ "O
3eratoplasty )+$ "O
#stigmatic surgery )+$ "O
&ataract e!traction )+$ "O
Phaco-emulsification )+$ "O
Intraocular lens implantation- P((# )+$ "O
44Intraocular lens implantation- 5oldable )+$ "O
'emoval intraocular foreign bodies )+$ "O
2laucoma procedures )+$ "O
443rupen valve implantation )+$ "O
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
44Parsplana posterior vitrecotomy )+$ "O
'epair retinal detachment and retinal holes )+$ "O
&ryotherapy for glaucoma or retinal problems )+$ "O
44*emporal artery biopsy )+$ "O
-iagnostic aspirate or biopsy )+$ "O
%#$+'$
44 #rgon-3rypton laser )+$ "O
o 'etinal photocoagulation
)+$ "O
o Iridectomy
)+$ "O
o *rabeculoplasty
)+$ "O
o Iridioplasty
)+$ "O
o +ndo-laser procedure
)+$ "O
o $uture cutting
)+$ "O
44 )ag laser )+$ "O
o #nterior and posterior capuslotomy
)+$ "O
o Peripheral iridectomy
)+$ "O
o Pupil iridoplasty
)+$ "O
o %ysis of vitreous strand
)+$ "O
44+!cimer laser )+$ "O
o Photorefractive 6eratectomy
)+$ "O
Injection of 2as )+$ "O
2laucoma *ube )+$ "O
$ilicone Oil Injection )+$ "O
%ocal /loc6 #nesthesia )+$ "O
'egional /loc6s #nesthesia for Ophthalmic Purposes )+$ "O
&onscious $edation-#dult )+$ "O
'adiography 1se of (odality . interpretation of images
7therapeutic and diagnostic8
)+$ "O
1ltrasound 1se of (odality . interpretation of images )+$ "O
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
7therapeutic and diagnostic8
5luoroscopy 1se of (odality with $tate %icense .
interpretation of images 7therapeutic and diagnostic8
)+$ "O
%ocal anesthesia )+$ "O
&onscious $edation )+$ "O
$upervision of &onscious $edation *rained 'egistered
"urse
)+$ "O
O*9+'$ "O* %I$*+-
)+$ "O
)+$ "O
)+$ "O
44 DOCUMENTATION OF TRAINING AND EXPERIENCE IS REQUIRED FOR THOSE
PROCEDURES

$ignature of #pplicant -ate

$ignature of :I committee chairperson -ate recommended

$ignature of 2overning /ody chairperson -ate recommended