Pre-Procedure Questionnaire

Please fill out as soon as possible so that our pre-admissions nurse is able to review your health information when she calls you 1-2 days prior to surgery. When you have completed the questionnaire, please press submit.

  • MM slash DD slash YYYY
  • Pre-Procedure Questionnaire

  • If yes, please remove your contacts prior to arrival and wear your glasses.
  • If yes, we will ask you to remove the aid that is on the same side as your surgery.
  • Please use your inhalers if normally used in the morning and bring your inhaler(s) with you.
  • Please take your heart medications in the morning, with a sip of water, if you normally do so.
  • 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.
  • If you take oral medications or insulin for diabetes, hold your medications the morning of surgery and bring with you.
  • If so, please bring a copy.
  • 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.


    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.

1720 Fourth Street Santa Rosa, CA 95404 (707) 546-8100