8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
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OTOLARYNGOLOGY SURGERY
I hereby request surgical privileges in the specialty of Otolaryngology 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 "PP#O$%& &%'I%&
"ntral lavage (%) 'O
*iopsy of nose or thynophoma (%) 'O
*iopsy of tongue (%) 'O
*iopsy of ear (%) 'O
*lepharoplasty (%) 'O
*ronchoscopy +diagnostic, (%) 'O
*row lift- conventional or endoscopic (%) 'O
.aldwell-/uc procedure (%) 'O
&ilation of esophagus (%) 'O
%ar piercing (%) 'O
%sophagoscopy- diagnostic or therapeutic (%) 'O
%thmoidectomy (%) 'O
%vacuation hematoma of nose or septum (%) 'O
%!cision of cancer of s0in (%) 'O
%!cision 12- biopsy of head and nec0 tumor (%) 'O
3acial nerve reanastomosis and2or graft (%) 'O
3acial resurfacing (%) 'O
3at transfer (%) 'O
3rontal sinustrephine- drainage or surgery (%) 'O
4enioplasty (%) 'O
I5& of superficial abcessess (%) 'O
/aryngoscopy- diagnostic or therapeutic- including (%) 'O
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
removal of foreign body
/aser assisted procedure6 .O7- 89P- ("4: ;-)witch-
$ersapulse2pulsed dye- %erbium
(%) 'O
/ingual tonsillectomy (%) 'O
:astoidectomy (%) 'O
:a!illofacial injuries- reduction 5 fi!ation (%) 'O
:icroscopic laryngoscopy (%) 'O
:yringotomy with2without placement of tubes (%) 'O
'asal septum2)ubmucous resection and2or septoplasty (%) 'O
Otoplasty (%) 'O
Pharyngoplasty (%) 'O
Plastic repair of head 5 nec0 laceration- scars- lesions
or tumors
(%) 'O
#econstruction of e!ternal auditory canal (%) 'O
#econstruction of soft tissues of face- head and nec0 (%) 'O
#emoval of head 5 nec0 foreign bodies (%) 'O
#hinoplasty (%) 'O
#hytidectomy +all areas, (%) 'O
#hytidoplasty (%) 'O
)alivary gland surgery +all types, (%) 'O
)0in grafting +small are- < diameter or less, (%) 'O
)inus endoscopic surgery (%) 'O
)inus surgery (%) 'O
)uction assisted lipectomy +all areas, (%) 'O
)uction assisted lipectomy- head 5 nec0 areas (%) 'O
9onsillectomy and2or "denoidectomy (%) 'O
9racheostomy (%) 'O
9ransnasal antrostomy (%) 'O
9urbinate surgery = conventional or laser (%) 'O
9ympanoplasty (%) 'O
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
9ympanotomy with e!plorations of middle ear (%) 'O
>vulopalatopharyngoplasty +>PPP, (%) 'O
Radiography Use of Modality & interpretation of images
therape!ti" and diagnosti"#
(%) 'O
Ultraso!nd Use of Modality & interpretation of images
therape!ti" and diagnosti"#
(%) 'O
$l!oros"opy Use of Modality %ith State Li"ense &
interpretation of images therape!ti" and diagnosti",
(%) 'O
Lo"al anesthesia (%) 'O
&ons"io!s Sedation (%) 'O
S!per'ision of &ons"io!s Sedation Trained Registered
N!rse
(%) 'O
O9?%#) 'O9 /I)9%&
(%) 'O
(%) 'O
(%) 'O

)ignature of "pplicant &ate

)ignature of ;I committee chairperson &ate recommended

)ignature of 4overning *ody chairperson &ate recommended