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Patient Education Class Reservation

Surgical Schedulers, please provide patient with FMH Pre-Surgical Education dates / times form for them to PICK their preferred class of attendance during their pre-op visit with their surgeon.  Please complete this internet reservation form as their preference form indicates.  Once completed, please print and provide theFMH Pre-Surgical Education registration confirmation to the patient with instructions for attendance to the class. This form serves as their registration comfirmation for the class.  Thank you! Any questions, contact Orthopedic Program Coordinator 240-566-3785.

* Indicates required information
Patient Name * 
Phone Number * 
Email Address 
Date Of Birth 
Surgeon 
Date of Surgery 
Procedure 
Planned Length of Stay 



Choose Class Date  * 
Interpreter Desired 

If Yes, Please Enter Interpreter Type 
Wheelchair Desired 

1:1 Request  

Additional Requests/Concerns 
 

Thank you again for choosing Frederick Memorial Hospital Joint Works Program for your elective joint replacement surgical procedure. We look forward to assisting you in taking that next step to a pain free joint! If you have any questions, please contact the Orthopedic Program Coordinator at 240-566-3785.
 

                   

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