Cataract Surgery Pre-Operative Checklist Form
Please complete this checklist to ensure readiness for your upcoming cataract surgery. All information will be used to support your safe and successful procedure.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Scheduled Surgery Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Surgeon or Clinic Contact Name
*
Have you reviewed and followed all pre-operative instructions provided by your care team?
*
Yes
No
Please list all current medications (or enter 'None')
*
Do you have any allergies to medications or other substances?
*
No known allergies
Yes (please specify below)
If yes, please specify allergies:
Do you have any of the following medical conditions? (Select all that apply)
*
Diabetes
Heart disease
Bleeding disorder
Currently taking blood thinners
None of the above
Will you have a responsible adult to escort you home after surgery?
*
Yes
No
I confirm that I have reviewed this checklist and all information provided is accurate to the best of my knowledge.
*
Submit Checklist
Submit Checklist
Should be Empty: