Patient Information Name (First) Name (Middle) Name (Last) Date of Birth Procedure Information Surgeon - Select - Maurice Collada, MD Seymur V Gahramanov, MD Charles V Hatchette II, MD Benjamin R. Kafka, MD Michael J Nanaszko, MD Surgery Date Contact Information Email Phone Statement of Attestation I understand the information that was presented and do not have any questions. I watched the presentation and have some questions – I would like to be contacted by the Nurse Navigator to review my questions. Read the code New code Please type the code above Submit