Transplant Surgery Preparation Checklist Form
Please complete the following checklist to confirm your readiness for your upcoming transplant surgery. This form ensures all key preparation steps are addressed for a smooth surgical experience.
Full Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Surgery Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you followed your fasting instructions (no food or drink after the specified time)?
*
Yes
No
Have you taken or withheld any medications as instructed by your care team?
*
Yes
No
Not Applicable
Do you have a responsible adult to accompany you to and from the hospital?
*
Yes
No
Have you arranged for post-surgery support at home?
*
Yes
No
Are you experiencing any signs of illness (fever, cough, sore throat, or infection)?
*
No symptoms
Yes, I have symptoms
Do you have all required documents and identification for hospital admission?
*
Yes
No
Is there anything else your care team should know before your surgery?
Submit Checklist
Should be Empty: