Bone & Joint Surgeons, Inc.
Pre-Surgical Check List
Date___________________
Patient name:______________________________________ Phone:_________________________________
□Clearance Required? Doctor: _______________________________________________________________
Personal history of DVT?_________________________ □ASA □PLAVIX
Diagnosis:_________________________________________________________________________________
Surgical Procedure:__________________________________________________________________________
_________________________________________________________________________________________
Length of procedure: __________________________________
Location: □GSH
□GSN
□MVH
□MVS
□GMH
□BHP
□KMC
Anesthesia: □GENERAL □SPINAL □LOCAL □LOCAL/MAC □SCALENE BLOCK □BIER BLOCK
□ADMIT
□23 OBS
□OP
□IN
□Mini C-arm
□C-arm
ABX:_______________________________ Pre-op Meds:___________________________________________
Special Eqiupment:__________________________________________________________________________
Position:______________________________________
Table:____________________________________
□Surgical procedure explained
□Surgical risk explained including infection, blood loss, blood clots, loss of limb, complications of
anesthesia, death, need for further surgery
□Skin numbness and scarring
□Recovery phase explained/how long off work
□Expected outcome after surgical procedure explained
□Opportunity given to ventilate feelings
□Verbalizes understanding of surgical procedures and risks
□Verbalizes compliance in regard to surgical procedures
□Alternatives to surgery discussed
□Instructed to call office if further questions/concerns/problems arise
□Patient realizes that unforeseen circumstances my necessitate changing or modifying the surgical
procedure at the time of surgery
This surgical procedure has been explained, as have the advantages and disadvantages. The possibilities and
nature of complications cannot be accurately anticipated and therefore there can be no guarantee expressed
or implied as to the result of surgery or as to a cure.
______________________________________________
Patient/Guardian Signature
_______________________________
Date
______________________________________________
Physician Signature
_______________________________
Date
______________________________________________
Witness Signature
_______________________________
Date