Microsoft word - preop instructions last revised october 2010.doc

Your Surgery Appointment Is: Date: ________ Time:______

18807 Beardslee Blvd.
Suite 102
Bothell, WA 98011
If Dr. Rubens has prescribed or given you a pre-operative sedative medication, (425) 489-8274
take ______ pills 1 ½ hours before your surgery with small sips of water. If Dr. Rubens has prescribed a narcotic pain medication: __________________. PRE-OPERATIVE INSTRUCTIONS
DO NOT take this medication before surgery. Take this medication after surgery if
IF YOU CHOOSE TO BE ASLEEP: YOU MUST BRING AN ESCORT to
Call The Office Or Dr. Rubens With Any Questions At: (425) 489-8274
bring you home and stay in the office for the duration of your surgery. A
responsible adult should be available to watch and help you for six hours.
INFORMATION YOU SHOULD KNOW ABOUT YOUR MEDICATIONS
It is necessary to have an empty stomach for anesthesia safety. Do not eat or
You have been prescribed several medications. Please note that some of
drink anything for six hours prior to your surgery except a small amount of apple
them have desirable effects as well as undesirable side effects! Many
juice or water to swallow your pills (about 1/2 of a Dixie cup).
medications that you may be taking, as well as alcohol may adversely interact
with anesthetic agents, pain medications, or antibiotics and cause serious harm
*** IF YOU HAVE AN AFTERNOON APPOINTMENT
to you or an unborn fetus. If you have a problem with alcohol or drug abuse, have
used Cocaine within the last two weeks, and you did not discuss this with Dr.
You may eat breakfast 6 hours before at: ______
Rubens, it is imperative that you bring this to his attention before your surgery.
Be sure to bring a list of your medications. If you have medications that you
You may drink clear liquids up until 3 hours before at : _______
would normally take in the morning, please take them unless specifically directed
(Clear liquids are: Water, Apple Juice, Clear Sport Drinks, Black Coffee, Tea, not to. If you have any questions, please call the office prior to your surgery. If
NO CARBONATED SOFT DRINKS, NO MILK PLEASE) you are presently taking any other medications including birth control pills, be
sure to tell Dr. Rubens. If you suspect that you may be pregnant, please tell Dr.
Your eyes may become dry during general anesthesia. Please remove your
Rubens before your surgery.
contact lenses prior to surgery to prevent an eye injury.
Narcotic pain medication will often cause nausea, dizziness, constipation, Wear comfortable loose clothing. For your safety, it will be necessary to use a
sleepiness, stomach cramps, wakefulness, anxiety, hiccups, itching, and hives. number of monitors and short sleeves often help when placing the blood pressure cuff. Narcotics may be addictive if abused and should never be mixed with alcohol, or be taken when operating dangerous machinery or performing tasks that require judgment, We recommend that you fill your prescriptions and go grocery shopping before your appointment. Also have some ice ready for application after your surgery. You may develop an allergy or become sensitive to an antibiotic. This may first Anti-inflammatory medication will help reduce pain and swelling after surgery. If you appear as a rash, unusual itching, hives, or persistent diarrhea. If you develop any of can take Aspirin, Ibuprofen, or Aleve® and do not have an allergy to these medications, these symptoms or signs, please call Dr. Rubens immediately. You will experience
kidney problems, or stomach ulcers, we recommend you take _____ ibuprofen or less nausea from your antibiotic (and narcotics) if you take your medication with
_____ Aleve (May use ______tsp. of elixir for children) _____hours before your surgery solid food for all doses after surgery such as starches.
Ibuprofen, Aleve, and other non-steroidal anti-inflammatory medications may If Dr. Rubens has prescribed an antibiotic: _____________________, _____ mg. cause dizziness, disorientation, nausea, itching, hives, and sleepiness. Kidney failure is Please take ___ pill/s____ hour(s) before your appointment. Continue to take the a recognized complication from taking too much ibuprofen. If you experience any of medication every ____ hours as prescribed until gone. Please note that your
these symptoms or are concerned in any way that you may be having an unusual antibiotic may reduce the effectiveness of "birth control pills!"
reaction to this medication before or after surgery, please contact Dr. Rubens If Dr. Rubens has prescribed an antibacterial mouth rinse, we will give you the first immediately. You will experience less nausea with Ibuprofen if you take your
rinse in the office before your surgery. Continue to rinse for 30 seconds and spit every medication with food for all doses after surgery.
12 hours for one week. Do not eat or drink anything after using the mouth rinse for 2 hours.

Source: http://rubens-steen.com/Forms/Pre-Op-Instructions.pdf