Kimberly Allen

 
 October 20, 2016 04:45 PM 
 TO:30103548930 FROM: 8330674930 
 Page: 80 
 360 
 PRE-SURGERY INSTRUCTIONS 
 ORTHO AND SPINE 
 COVID symptoms. If you arrive to the surgery center with symptoms 
 and do not have proof of a NEGATIVE (-) test result, your surgery will be 
 cancelled. 
 Initial 
 Prior to your surgery, please be sure to complete the following: 
 CASS Pre-Procedure Medical History and Medication Reconciliation Forms 
 Current Medications/Vitamins: Review list provided on Pages 2 & 3 and follow all guidelines. 
 Bloodwork must be completed within 30 days of your surgery. 
 These include: Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and 
 Prothrombin Time (PT/INR) which will measure how long it takes your blood to clot. 
 We will provide you with the order for the bloodwork at your Pre-Operative Appointment. 
 DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT ON THE NIGHT 
 BEFORE YOUR SURGERY 
 AND 
 PLEASE ARRIVE ON TIME TO THE SURGERY CENTER. 
 My signature is proof that I have read and understand that failing to follow the above guidelines will cause 
 a delay in my treatment due to surgery cancellation. 
 PATIENT/GUARDIAN SIGNATURE Chil E 
 DATE. June 18, 2019
