Anaesthesia Billing Form Generator

Single-file, no server. Data stays in this browser unless you export or print it.

Provider

Provider name Provider number Provider email

Upload signature image

No saved signature image

Uploaded signature images are saved locally in this browser and reused for new entries until removed. Use PNG/JPG/WebP/SVG; TIFF usually will not render in browsers.

Manual signature capture

Patient details

Patient URN Date of birth Surname Given name Sex Details

Procedure / theatre

Date Pre-op consult Op no.

No procedure selected

Start Finish Item number Duration (hh:mm) Patient age at surgery ASA category Emergency case After hours calculated Modifier 1 Modifier 2 Modifier 3

ASA modifiers: ASA 1–2 none, ASA 3 = 25000, ASA 4 = 25005, ASA 5 = 25010. Emergency modifiers: if emergency is ticked and more than 50% of the case falls after 8pm/before 8am on weekdays or any time on weekends, modifier = 25025; otherwise emergency during business hours = 25020. Age modifiers: under 4 years = 25013, 75 years or older = 25014.

Billing allocation

Patient classification Billing allocation

Referral details

Referring doctor Date of letter Referring doctor address

Item rows

Additional items

Comments

Save / export

Tip: use browser print to save as PDF. The email button creates an Outlook-compatible .eml file. For sensitive patient data, avoid shared computers and clear saved drafts when finished.

Region / category Search / wildcard

Use words or wildcards. Examples: lens, cleft*, *biopsy*. Click a result to insert the item number into Op no.

Item	Region	Procedure description

Optional: paste CSV catalogue

CSV format: ITEM,Region,Procedure Description. Saved locally in this browser.