Surgical Preference List
Document and communicate surgeon and team preferences for surgical procedures to ensure optimal operating room setup.
Procedure Name
*
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgeon's Name
*
First Name
Last Name
Patient Initials or ID (do not use full name or sensitive ID)
*
Type of Anesthesia
*
General
Regional
Local
Sedation
Other
Patient Positioning
*
Supine
Prone
Lithotomy
Lateral
Sitting
Other
Required Instruments & Equipment
*
Draping Preferences
Suture Materials and Sizes
Implants or Consumables Needed
Additional Notes or Special Instructions
Prepared by (Name and Role)
*
Submit Preference List
Should be Empty: