Surgical Case Readiness Form
Use this form to capture the information needed to prepare and coordinate a surgical case.
Patient and Case Details
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record / Case Identifier
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
Planned Procedure Name
*
Surgeon Name
*
First Name
Last Name
Preoperative Readiness
Fasting / NPO Status
*
Compliant
Not compliant
Unsure
Pre-op Checklist Completion
*
Consent confirmed by team only if operationally needed
Site marked
Equipment available
Labs/imaging reviewed
Anesthesia clearance obtained
Allergies reviewed
Implant / Instrument Needs
Special Equipment or Supplies Required
Readiness Issues or Blockers
Day-of-Surgery Coordination
Anesthesia Type / Plan
*
General
Regional
Local
Monitored anesthesia care
Other
Case Priority / Urgency
*
Routine
Urgent
Add-on
Emergency
Other
Estimated Duration
*
Patient Arrival / Transport Status
*
Confirmed
Pending
Delayed
Not applicable
Other
Additional Notes / Instructions for Surgical Team
Submit
Should be Empty: