8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
ANESTHESIA
I hereby request privileges in the specialty of Anesthesia as shown on 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.
Documentation of training and experience is attached for those procedures marked by an asterisk !".
#he following privileges are requested and are consistent with my abilities$ training and experience.
PRIVILEGES APPROVED
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%&''()#*
+eneral Anesthesia for
,ediatric -(* )&
Adult -(* )&
.ocal stand-by -(* )&
Intravenous regional block -(* )&
/egional Anesthesia -(* )&
.umbar epidural block -(* )&
Axillary block -(* )&
%audal block -(* )&
Interscalene block -(* )&
0locks of nerves of upper and lower extremities -(* )&
*tellate ganglion block -(* )&
(pidural 0lock -(* )&
*pinal 0lock -(* )&
0ier 0lock -(* )&
Axillary nerve block -(* )&
#rigger ,oint block -(* )&
&ccipital nerve block -(* )&
0%.* -(* )&
A%.* -(* )&
I1 *edation -(* )&
'onitored Anesthesia %are -(* )&
IntraDiscal (lectro#hermal #herapy ID(#" -(* )&
/adiography 2se of 'odality 3 interpretation of
images therapeutic and diagnostic"
-(* )&
2ltrasound 2se of 'odality 3 interpretation of
images therapeutic and diagnostic"
-(* )&
4luoroscopy 2se of 'odality with *tate .icense 3
interpretation of images therapeutic and diagnostic"
-(* )&
.ocal anesthesia -(* )&
%onscious *edation -(* )&
*upervision of %onscious *edation #rained
/egistered )urse
-(* )&
"#H$%S N"# &'S#$( -(* )&
-(* )&
-(* )&
555555555555555555555555555555555555555555555 555555555555555555555
*ignature of Applicant Date

*ignature of 'edical Director 67ason *nibbe$'D8 Date recommended

*ignature of 'anaging 'ember 69iarash 'ichel$ 'D8 Date recommended