Plastic Surgery Pre-Op Order Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Weight (kg)
Height (cm)
Health Insurance ID
Health Insurance Type
Emergency Contact Details
Contact Person Name
First Name
Last Name
Primary Phone Number
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Medical Data
Admission Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Blood Type
A
B
AB
O
Do you have any known allergies? If yes, then please specify below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.?
Pre-Operative Order Information
Date of Surgery
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Laboratory Tests Taken
CBC
Chest X-Ray
ECG
EKG
Urinalysis
PT/PTT Studies
MRI Scan
CT Scan
Ultrasound Test
Endoscopy
Preoperative Diagnosis
Surgery Procedure Name
Pre-Operative Medications
Rows
Medication Name
Route
Dose
1
2
3
4
5
6
7
8
9
10
Surgeon Name
First Name
Last Name
Surgeon Contact Number
-
Area Code
Phone Number
Surgeon Signature
Signed Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: