115 SW Allen Road
Bend, Or 97702
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Fax:

Preoperative Check-List
and Surgery Policies

Patient Name______________________________ DOB__/__/__
Planned Surgery or Procedure______________________________

Please circle the following locations where we can telephone you (Cross-out if NO):
Home_______________ Work_______________ Other_______________

Please circle the following locations where we can leave a message (Cross-out if N0):
Home_______________ Work_______________ Other_______________

If we cannot telephone you at home or work, then please provide other number(s) where we can reach you by telephone:
_______________ _______________

Please initial each item to confirm your agreement. [Print "NO" if you disagree.]

You permit visiting physicians or nurses to observe your surgery.

You agree to avoid aspirin and ibuprofen (and other NSAIDS) for 10 days prior to surgery; to avoid decongestants for 3 days prior to surgery; to avoid Fastin (phentermine), Zoloft, Prozac or other antidepressants, Vitamin E supplements and herbal remedies (unless approved by your surgeon) 7 days before surgery. We recommend that you remove all aspirin and ibuprofen containing products and similar products from your medicine chest.

If another physician prescribes new medications for you, then please notify the Laser Medical staff. Have any prescriptions from Dr. Van Camp filled prior to the procedure and take as directed.

You agree not to drive yourself home after surgery and to not drive an automobile until the day after surgery. Tell us if you have difficulty arranging transportation so we may help you.

If you develop a rash, skin infection, wound or illness anytime prior to surgery, then you will notify Laser Medical staff.

Occasionally your surgeon will require a letter from your primary care physician to verify your health status. This letter should be received two weeks before surgery, or your procedure may have to be rescheduled for a later date.

Payment Schedule: It is our office policy to ask patients to pay half of the total surgery fee as a down payment at the time the surgery is scheduled. The balance of the fee is to be paid 14 days before the surgery as your final payment. This is often the day of the pre-op visit.

Schedule Changes or Cancellations: If it is necessary to change or cancel the date of the surgical procedure, then at least one week notice is required. The patient should document the date and time, and to whom the notice was given. Last minute cancellations due to illness must be documented in writing by a physician. If you would like to revise the plan of body areas designated for liposuction, you will need to notify us at least one week before surgery.

Cancellation Charges: Once the initial down payment is made your surgery is scheduled. Our facilities and staff are scheduled just for your procedure. Any reschedule that is done with less than one week notice may result in a $300 rescheduling fee. If the surgery is cancelled by you for any reason, there may be a $300 fee to cover administrative expenses. Thank you for your understanding in this matter.

Pre-Op Telephone Calls: Our staff routinely telephones patients for confirmation two to four days before surgery. If we are unable to reach you, please call us 48 hours before the surgery to confirm the exact date and time of arrival.

I have read and agree to the above policies. I also consent to routine pre-operative laboratory tests (which may include an HIV test) if the physician determines that these are needed. The results of these tests will be placed in the patients chart and will remain strictly confidential.

1. Antibiotics, such as cefadroxil (Duricef ), cephalexin (Keflex), Azithromycin (Zithromax), or ciprofloxacin (Cipro ) may be prescribed in order to minimize the risk of a surgical infection. Antibiotics may be taken with food to reduce the risk of gastric upset. Please start taking your antibiotic the day before surgery, and continue until the entire supply is completed. If your surgery is scheduled to begin in the early morning (before 9:00 a.m.), taking your antibiotic and eating should be postponed until after surgery.
   
   
2. Lorazepam (Ativan ) is a mild sedative, and a mild sleeping pill, that does not make one feel "drugged". Surgery is more easily tolerated if the patient is well rested and relaxed. You may take one lorazepam the night before surgery if needed for sleep.
   
   
3. Mephytone (Vitamin K) can help minimize bleeding and postoperative bruising. Most patients with good nutrition do not require it but it may be prescribed for some patients. Take one 5 mg tablet daily, beginning two weeks before the surgery.
   
   
4. Acetaminophen (Tylenol Extra Strength), 500 mg capsules or tablets, does not require a prescription. Taking two tablets, three to four times daily, beginning after surgery, should help minimize postoperative swelling. Take 2 Extra Strength Tylenol (acetaminophen), 500 mg each, as needed, to treat any minor pain before surgery. If you have more severe pain uncontrolled by ice packs and Tylenol, your should notify the physician immediately
   
   
5. Diphenhydramine (Benadryl ) 25mg capsules or tablets, does not require a prescription. Taken as directed it can help to reduce post-operative itching. Be aware that Benadryl may cause drowsiness.
   
   
6. Medication Precautions: Do Not Take ASPIRIN (Anacin, or Bufferin) or IBUPROFEN (Advil, Motrin, or Nuprin), or NAPROXEN (Aleve), or any medications that contain these drugs or any similar anti-inflammatory medications, for 7 to 10 days before and 3 days after surgery. These drugs will promote bleeding and bruising. Check the labels of all your medications, even those which you purchase without a doctor's prescription to be sure you are not taking any aspirin or aspirin-like substances. Remove any products containing aspirin from your medicine chest so that you do not inadvertently take it during the week before your surgery. Consult your physician before you stop taking any prescribed medicines. Please inform us if you are taking any medications to treat arthritis or inflamation, or any blood-thinning anti-coagulant medications. Below is a list of medications that may need to be stopped. (Most of them contain aspirin or an NSAID)
   
   

   Advil	Children's Aspirin	Excedrin	Magan	Pamprin	Synalgos DC
   Aleve	salicylate	Feldene	Mg sallicylate	Pepto-bismal	Tanacetum
   Alcohol	Clinoril	fenoprofen	meclofenamate	Percodan	feverfew
   Alka Seltzer	Congesprin	feverfew	Meclofen	Persantine	Tolectin
   Amigesic	Cope	Fiorinal	Medipren	Phenaphen	tolmetin
   Anacin	Coricidin	flurbiprofen	mefenamic	Phenylbutazone	Toradol
   Anaprox	corticosteroids	Froben	Menadob	piroxicam	Trandate
   Anaproxin	Coumadin	4-Way Cold	Midol	Ponstel	Trendan
   Ansaid	Darvon ASA	Garlic Capsules	Mobidin	Prednisone	Trental
   APC	Darvon Compound	Gelpirin	Monogesic	Quagesic	Trigesic
   Argesic	Daypro	Genpril	Motrin	Relafen	Trilisate
   Arthra G	Depakote	Genprin	nabumetone	Rexolate	Tusal
   Arthropan	dexamethasone	Ginko Biloba	Nalfon	Robasissal	Vanquish
   A.S.A.	diclofenae	Goody's	Naprosyn	Roxiprin	Vitamin E
   Ascodeen	dipyridamole	Haltran	naproxen	Rufln	Voltaren
   Ascriptiii	Disalcid	Halfprin	Norgesic	Saleto	Warfarin
   Aspergum	divalproex	Ibuprin	Norwich Ex.Str.	Salflex	Willow Bark
   Aspirin	Doan's Pills	ibuprofen	Nuprin	salsalate	Zactrin
   BC Powder	Dolobid	lbuprohm	Ocufen	Salsitab	Zorprin
   Baby Aspirin	Dristan	Indameth	Orudis	Sine Off
   Bayer	Easprin	Indocin	Oruvail	Sine Aid
   Brufen	Ecotrin	indomethacin	oxyphenbutazone	thiosalicylate
   Bufferin	Empirin	ketoprofen	Oxybutazone	Soma Compound
   Butazolidin	Emprazil	ketorolac	oxaprozin	sulindac
   Cephalgesic	Endodan	Lortab ASA
   Cheracol Caps

   
   
7. Do not take decongestant medication containing pseudoephedrine (Sudafed, Actifed ) for 3 days prior to surgery. These can cause the heart rate to beat too rapidly. Appetite suppressant drugs phentermine (Fastin), should not be taken for at least a week before surgery. To avoid side effects reduce these gradually over two weeks before surgery. Maintain a healthy diet for safe surgery and good health.
   
   
8. Please consult you prescribing physician before discontinuing any of your prescribed medications. Discuss them with Dr. Van Camp.

Patient Signature__________________ Date __/__/__
Witness Signature__________________ Date __/__/__