Post-Operative Care Agreement
Please review and complete this form to confirm your understanding and acceptance of post-operative care instructions.
Patient Full Name
*
First Name
Last Name
Patient Email Address
*
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Surgery/Procedure
*
-
Month
-
Day
Year
Date
Type of Surgery/Procedure
*
Responsible Physician/Surgeon Name
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any allergies or relevant medical conditions
Please read and acknowledge each post-operative care instruction below.
*
Rows
I have read and understand
Take all prescribed medications as directed
1
Attend all scheduled follow-up appointments
2
Monitor incision site for signs of infection (redness, swelling, discharge)
3
Contact the clinic if you experience severe pain, fever, or unusual symptoms
4
Avoid strenuous activity until cleared by your physician
5
Follow dietary restrictions as instructed
6
Keep wound clean and dry as instructed
7
Patient Signature
*
Submit Agreement
Submit Agreement
Should be Empty: