Pediatric Pre-Operative Checklist

Child's Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Age

Sex / Gender

Parent / Guardian Full Name

First NameMiddle NameLast Name

Relationship to Child

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Procedure Name

Planned Procedure Date

Date

Planned Arrival / Check-in Time

Hour Minutes

AM/PM Option

Operating Physician / Surgeon

First NameMiddle NameLast Name

Referring Provider (if applicable)

Facility / Location

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Current medications

Medication allergies

Latex allergy

Food allergies

Chronic medical conditions

Prior surgeries or procedures

History of anesthesia problems

Recent illness or fever within the last 2 weeks

Bleeding or breathing concerns

Other medical conditions or concerns

Has the child followed all pre-operative instructions?

Was fasting (NPO) instructions followed?

Has the child bathed or completed skin preparation as instructed?

Has the child arrived with all required documents?

Have all jewelry and nail polish been removed?

Has the child taken any medications today?

If any instructions were missed or not fully followed, please explain

I have reviewed and understand the pre-operative instructions and authorize my child’s surgical evaluation and preparation

Pediatric Pre-Operative Checklist

Patient and Guardian Information

Procedure and Scheduling Details

Medical History and Current Health Status

Pre-Operative Preparation Checklist

Consent and Acknowledgment