Ambulatory Surgical Center
Name: ___________________________________________ Date: ____________
Your Surgery has been scheduled with Dr._________________________________ in the
Ambulatory Surgical Center.
Date of Surgery: ______________________ Time of Surgery: ________________
Arrival Time at the Ambulatory Surgical Center: ___________________________
*Surgery times will sometimes be changed. Please be available by phone on the day of
surgery so that you can be notified of any changes as soon as possible.
Patient Instructions
What to do next…
 Call your Primary Care Doctor as soon as possible to set up an appointment for a PreOp History and Physical. This appointment may include labwork, an EKG, or a Chest
X-Ray. Your physical must be dated no later than 30 days before your surgery.
 Take the enclosed History and Physical form and the Preoperative Testing
requirements to your Primary Care Doctor for completion.
 Please have your Primary Care Doctor fax the completed History and Physical form and
your lab/EKG/Chest X-ray results to our ASC Secretary, Linda, at 443-568-0111. Your
doctor can contact us at 410-644-1880 ext.102 with any additional questions.
 Make arrangements for someone to drive you home after surgery and to stay with you
the first 24 hours after your surgery.
What to do the night before your surgery…
 If possible, shower with a mild soap. This helps to reduce the amount of “normal” skin
bacteria present on the skin before surgery.
 Do not eat or drink anything after midnight. If you should eat or drink anything, your
surgery may need to be cancelled. It is dangerous to have food or fluids in your
stomach when your receive an anesthetic. Needed medications can be taken with a
“sip” of water.
 Do not smoke. Your lungs must be clear of smoke before anesthesia
Additional Instructions…
 Blood thinning medication such as Coumadin or Heparin or Plavix, as well as Aspirin
products should be stopped 72 hours before your surgery or at the advice of your
physician. PLEASE CHECK WITH YOUR FAMILY PHYSICIAN BEFORE STOPPING
ANY MEDICATIONS!!!!
 Medications such as: Aleve, Advil, Motrin, Daypro, Lodine, Relafen,Celebrex etc.
should be stopped 10 days before your surgery.
 If you will need to be using crutches, splints, or other assistive devices, please make an
appointment for instruction and/or fitting a few days before your surgery.
 Herbal supplements should be stopped 10 days prior to your surgery. (i.e. gingkobiloba,
St. John’s Wart, etc.)
What to do the day of surgery…
 Arrive at the Benson Ave. office at least 1 ½ hours before your surgery time.
 The Surgical Center Reception Area is to the left of the waiting room as you enter the
office. There, you will be greeted and registered by Linda.
 Again, do not eat or drink anything unless you have been instructed to do so by a
member of the Surgical Center Staff.
 Bring a responsible adult to drive you home. You may take a taxi if this adult
accompanies you. You will not be allowed to take a taxi alone.
 Do not wear any makeup or nail polish the day of surgery.
 Please leave all jewelry and valuables at home.
 Please bring any splints or crutches that you will need for your postoperative care. Your
doctor will let you know if you need these.
 Wear comfortable, casual clothing that will be easy to get on and off. In addition, wear
shoes with good traction.
 Bring a list of any medications, herbs, or vitamins that you are taking. You may take
medications with a “sip” of water as directed by the anesthesiologist. If you are a
diabetic, please bring your insulin or medication with you but do not take it.
** Our Pre-Op Nurse will call you a few days before surgery to review these
instructions and to answer any questions that you may have. The nurse will also
review your medical history with you.
Your Post Operative Appointment is:____/____/_____ @___________am / pm
If you have any questions, please contact the ASC at 410-644-1880 ext.102. We look
forward to seeing you and to providing for your care.
Orthopaedic Associates of Central Maryland
Ambulatory Surgical Center
GUIDELINES FOR PREOPERATIVE TESTING
HISTORY & PHYSICAL
 All Patients – Dated within 30 days of surgery unless
recent update is clinically necessary.
- Must cover potential causes of perioperative
morbidity.
- It is the basis for all other tests.
NO OTHER TESTS
 Healthy Children age 14 and older.
 Patients for local anesthesia only (no sedation)
CBC
 Patients age 15 and older.
PREGNANCY TEST

All women of childbearing age (may sign waiver
instead)
EKG
 Men age 40 and older
 Women age 50 and older (age 40 if post menopausal)
CHEST X-RAY
 Unstable pulmonary disease or debilitating pulmonary
episode within 6 months
CHEMISTRY
 Patients with diabetes, heart, renal adrenal or thyroid
disease.
 Patients taking diuretics, digoxin, chemotherapy or diet
medications.
COAGULATION STUDIES
 Patients taking anticoagulants need PT and PTT on the
day of surgery.
 Patients with a history of bleeding disorder.
The above are guidelines; surgeons/primary care physicians may order additional preparatory
measures for any patient as deem necessary by the surgical procedure, physician preference or
patient’s health.
PLEASE FAX TEST RESULTS AND HISTORY PHYSICAL TO:
ATTN: LINDA @443-568-0111 OR IF YOU HAVE QUESTIONS 410-644-1880 EXT.102
Orthopaedic Associates
Of
Central Maryland
PT. NAME__________________________________
D.O.B _____________________________________
PHONE # __________________________________
PLANNED SURGERY____________________________________________________
______________________________________________________________________
CC/ Surgical DX _________________________________________________________
HPI ___________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Past Med/Surgi Anesthesia History __________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Family/Social History______________________________________________________
______________________________________________________________________
Medications______________________ Allergies ___________________________
________________________________
___________________________________
________________________________
___________________________________
________________________________
___________________________________
________________________________
___________________________________
________________________________
___________________________________
________________________________
___________________________________
Alcohol__________________________ Tobacco____________________________
________________________________ Drugs______________________________
Recent HX of: Coumadin
Aspirin
Steroids
Contagious Disease
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Name:
Review of Systems (check positives and add comments below)
 Heent
 Pulmonary
 Cardiovasc
 Breast
 GI
 Hepatobiliary
 GU/Renal
 Hemato/coag
 Endocrine
 Musculo/Skel
 Dermatologic
 Neuro/Psych
Comments:________________________________________________________________________
PHYSICAL EXAM: P_________ R_________ BP_________ T________ HT________ WT________
General/Reliability __________________________________________________________________
_________________________________________________________________________________
Head/Neck _______________________________________________________________________
_________________________________________________________________________________
Lungs/Thorax _____________________________________________________________________
_________________________________________________________________________________
Heart/Pulses/Veins _________________________________________________________________
_________________________________________________________________________________
Breasts __________________________________________________________________________
_________________________________________________________________________________
Abdomen _________________________________________________________________________
_________________________________________________________________________________
Genito/Rectal _____________________________________________________________________
_________________________________________________________________________________
Musculoskeletal ___________________________________________________________________
_________________________________________________________________________________
Skin _____________________________________________________________________________
_________________________________________________________________________________
Neuro/Psych ______________________________________________________________________
_________________________________________________________________________________
LABS
 CBC
 EKG
 Lytes
 Chest
 PT/PTT
 Other
_______________________
_______________________
_______________________
_______________________
Diagnoses ______________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
 Cleared for Surgery
Signature: _____________________________ Date:__________
The above are guidelines; surgeons/primary care physicians may order additional preparatory measures for any patient as deem
necessary by the surgical procedure, physician preference or patient’s health.