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Dr. Christian Eccles
Hip and Knee Replacement Surgery
2940 E. Banner Gateway Dr. #200, Gilbert, AZ 85234
1675 E Melrose St, #101, Gilbert, AZ 85297
Phone: 480.964.2908 | Fax: 480.388.3519
Medical Assistant (Reese) extension: 3186
Surgery Scheduler (Debbie) extension: 4141
Physician Orders
________________
CT Scan without contrast Patient Name
of the ❏ Right Knee
❏ Left Knee
TMINI Total Knee Protocol
Diagnosis: Upcoming Tmini Robotic Total Knee Replacement
I hereby authorize SimonMed/SimonCare to act on my behalf to obtain any and all
authorizations needed for the above-named patient. I hereby certify that the test ordered is
medically necessary for the diagnosis and treatment of this patient.
