8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
PODIATRY SURGERY
I hereby request surgical privileges in the specialty of Podiatry 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.
!pplied for !pproved
"uperficial s#in lesion of the foot $%" &'
"ubcutaneous s#in lesion( ganglion( bursa( lipoma( others
pertaining to the foot
$%" &'
)enotomy( capsulotomy of the foot $%" &'
Intermetatarsal neuronectomy $%" &'
Partial or complete toenail avulsion with*without
matriectomy
$%" &'
"ubungual eostectomy of the foot $%" &'
+esser digital( partial osteotomy( eostectomy( etc. of
the foot
$%" &'
,allu( partial osteotomy or eostectomy - condylectomy
or supernumerary bones
$%" &'
'pen reduction - digit fracture of the foot $%" &'
%cision of plantar fibromatosis $%" &'
+esser metatarsal head resection( partial*complete
buionette
$%" &'
'steotomy of lesser metatarsals with internal fiation $%" &'
'steotomy of lesser metatarsal head*nec# with*without
internal fiation
$%" &'
.unionectomy( "ilver $%" &'
.unionectomy( /eller $%" &'
.unionectomy( 0c.ride with*without sesamoidectomy $%" &'
.unionectomy( /eller with implant $%" &'
.unionectomy( !#in $%" &'
!11%1 23*24*32
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
.unionectomy( modified 0ayo or "tone $%" &'
.unionectomy( aductus osteotomy with internal fiation $%" &'
.unionectomy( !ustin hori5ontal 6 osteotomy $%" &'
"esamoidectomy $%" &'
1orsal cuneiform eostectomy $%" &'
Plantar calcaneal eostectomy and*or plantar facial
release
$%" &'
'pen reduction - metatarsal fracture $%" &'
1igital arthrodesis $%" &'
"yndactylism $%" &'
7orefoot tendon transfer $%" &'
8etrocalcaneal eostosis $%" &'
8epair navicular tuberosity or accessory navicularis
without tendon transfer
$%" &'
)otal replacement of first metatarsal phalangeal joint $%" &'
)otal forefoot joint replacement of lesser 0.P. or I.P.
joint
$%" &'
8epair navicular tuberosity or accessory navicularis with
tendon transfer
$%" &'
)arsal tunnel release $%" &'
Pan matatarsectomy $%" &'
Radiography Use of Modality & interpretation of iages
!therape"ti# and diagnosti#$
$%" &'
Ultraso"nd Use of Modality & interpretation of iages
!therape"ti# and diagnosti#$
$%" &'
%l"oros#opy Use of Modality &ith State 'i#ense &
interpretation of iages !therape"ti# and diagnosti#9
$%" &'
'o#al anesthesia $%" &'
(ons#io"s Sedation $%" &'
S"per)ision of (ons#io"s Sedation Trained Registered
*"rse
$%" &'
'),%8" &') +I")%1
$%" &'
!11%1 23*24*32
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
$%" &'
$%" &'

"ignature of !pplicant 1ate

"ignature of :I committee chairperson 1ate recommended

"ignature of ;overning .ody chairperson 1ate recommended
!11%1 23*24*32