Pre-Procedure Questionnaire

Patient Name

First Last

Date of Surgery

Surgeon

Procedure

Phone (home)

(Cell)

Who will be giving you a ride home?

Phone

1) Do you have any allergies to medicine, latex, iodine, food or tape?

Yes
No

List what you are allergic to and what type of reaction you have)

2) Do you wear contact lenses?

If yes, please remove your contacts prior to arrival and wear your glasses.

Yes
No

Do you wear hearing aids?

If yes, we will ask you to remove the aid that is on the same side as your surgery.

Yes
No

Do you wear a prosthesis?

Yes
No

Type of prosthesis

3) Have you had a sore throat, cold or fever within the past 5-7 days?

Yes
No

Are you on antibiotics?

Yes
No

List antibiotics

4) Do you have breathing problems?

Yes
No

Type of breathing problem

Do you use oxygen at home?

Yes
No

If so, how many liters?

Please use your inhalers if normally used in the morning and bring your inhaler(s) with you.

5) Do you have heart problems?

Yes
No

Type of Heart Problem

Do you take heart medications?

Please take your heart medications in the morning, with a sip of water, if you normally do so.

6) Do you have high blood pressure?

Yes
No

Do you take medications for your pressure?

If you normally take your blood pressure medications in the morning, please do so with a small sip of water. If you take diuretics for your pressure, do not take them prior to surgery.

7) Do you have diabetes?

Yes
No

List diabetes medications

If you take oral medications or insulin for diabetes, hold your medications the morning of surgery and bring with you.

8) Have you ever taken the medication Flomax?

Yes
No

If you are having cataract surgery, is your surgeon aware of this?

Yes
No

9) Please list any medications not previously mentioned

10) Do you have any special needs we should be aware of while you are with us?

Yes
No

Please list

11) Do you have an advanced directive?

If so, please bring a copy.

Yes
No

Further Pre-Procedure Instructions

1) You will need to be here 1 hour prior to your scheduled surgery. We will call to confirm the time. Please be aware that changes in surgery times do occur. The staff at 4th Street Laser & Surgery Center staff has the final determination. We will notify you of any changes.

2) You will need someone to drive you home. We ask that they be here when your surgery has ended.

3) If your surgery is before noon, we ask that you not eat or drink after midnight.

If your surgery is at 12 noon or later, you may have clear liquids (black coffee, water, or tea without cream or sugar), 4 hours prior to scheduled arrival time, then nothing to eat or drink.

Any variation of the above instructions may cause a delay or cancellation of your surgery. We will review these instructions with you when we call prior to surgery.

4) Please wear a short-sleeve V-neck or button-down blouse/shirt. It is cold in the operating room, so you are welcome to wear warm socks/shoes and/or a vest.

5) Bring your insurance card(s) with you. As a courtesy, we will bill your insurance company(s).

6) No makeup, hairspray, jewelry/valuables, perfume or cologne (as we are a fragrance-free facility).

7) If you are having surgery with Dr. Kersten, do not wear metal, i.e. bra hooks, zipper, snaps etc., as cautery may be used.

8) If you are the first patient of the day, the front door will be opened 5 minutes before your scheduled arrival time. There is a doorbell to the left of the main door if there is an emergency.

9) If you are a patient of Dr. Kersten’s, we will ask you the name and number of your pharmacy, when we call, should we need to call in a prescription for you to use post-operatively.

10) If you are having cataract surgery, you will have eye drop(s) ordered that you will need to pick up prior to surgery.

Location

4th Street Laser & Surgery Center is located at 1720 Fourth Street between Alderbrook and Talbot.

Eye Care Institute, your surgeon’s office, has two locations in Santa Rosa, one of which is located on Fourth Street as well, (720 Fourth Street - we know, very confusing). If you end up downtown, behind Barnes and Noble, you are in the wrong place.