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Elite Surgical - Pre Operative Instructions
Please leave blank:
Patient Name
First Name:
Last Name:
Patient Address
Street Address:
Address Line 2:
City:
Post Code:
Country:
Patient Phone Number:
Mobile number:
Patient Date of Birth:
Operation Details
Consultant's Name
First Name:
Last Name:
Hospital Name:
Proposed Procedure:
Date of Surgery:
Length if Stay:
Please select…
Day case
Overnight
Anaesthetic:
Please select…
TIVA
GA
Sedation
LA
Anaesthetist's Name
First Name:
Last Name:
Pre Operative Instructions
The patient has been given pre operative instructions on the following:*:
Hair Extensions
Piercings
Contact Lenses / Glasses
Teeth / Crowns / Dentures
False Nails / Nail Varnish
Smoking
Alcohol
HRT
Contraceptive
Fasting
Pain Management
In Patient Stay & Discharge Information
VTE
Blood Transfusion
Underwear Information
Suture Removal
Surgery Advice
Other
Additional comments:
Declaration
Has the anaesthetist & surgeon received a copy of the patients pre operative questionnaire?
Please select…
YES
NO
Has the anaesthetist or surgeon ordered any investigations or highlighted anything the Hospital need to be aware of?
Please select…
YES
NO
The patient has confirmed the the medical details that they have provided on their pre operative questionnaire is accurate and complete. The patient understands that withholding any medical information may be detrimental to their health and safety during any procedure*:
Please select…
YES
NO
The surgeon and anaesthetist have both confirmed the patient is fit for admission to the Hospital:
Please select…
YES
NO
Elite Surgical Signature (Please Type Name):
Today's Date:
By clicking 'I agree', I agree that the signature above will be the electronic representation of my signature - just the same as a pen-and-paper signature.
I agree
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