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Healthcare & Wellness
Pre-Surgery Preparation Checklist
Patients confirm fasting, medication holds, and transport before surgery day — signed and time-stamped, so nothing slips.
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Preview · not interactivePre-Surgery Preparation Checklist
Patients confirm fasting, medication holds, and transport before surgery day — signed and time-stamped, so nothing slips.
Patient name*
Exactly as it appears on your booking, so we can match your record.
Procedure*
As written on your surgery letter
Surgery date*
Pick a date📅
I will not eat or drink anything from midnight before my surgery (unless my care team told me otherwise)*
I will not eat or drink anything from midnight before my surgery (unless my care team told me otherwise)
I have paused blood thinners and any other medications my care team asked me to stop*
I have paused blood thinners and any other medications my care team asked me to stop
Not sure which ones? List every medication below and add your question at the end — do not guess.
Someone is arranged to drive me home and stay with me after the procedure*
Someone is arranged to drive me home and stay with me after the procedure
I will remove all jewelry, piercings, and nail polish before arriving*
I will remove all jewelry, piercings, and nail polish before arriving
I have arranged help at home for the first days of recovery*
I have arranged help at home for the first days of recovery
Medications you currently take
Questions or concerns for your care team (optional)
Confirmation*
Confirmation
Patient signature*
Sign here
Sign with your finger or mouse — this confirms the checklist above.
Submit