**tett

**tett Jess mg, ma., Department of Surgery Division of Plastic 8 Reconstructive Surgery punt nai PRE-OPERATIVE INSTRUCTIONS S E. 98th Street, 14th fl. Ste. B New York, NY 10019 Office TM: Office Fax: Name of Patient: veC Name of Operation: Operation Date:CBI I Operation Time: 3pn Am / Pm Arrival Time: a ni pry-1 Am / Pm NOTE: YOU MUST FOLLOW THE INSTRUCTIONS OUTLINED NEXT TO ANY CHECKED BOXES BELOW. Call Elsa at option 1, the BUSINESS DAY before surgery, to confirm surgery time. J You need pre-testing (blood tests, EKG, physical) Pre-testing will be done at Mount Sinai Hospital 10 Union Square East on 141" Street, Suite 3 B, Third floor. Date of Pre-testing: / J Time: :_ am / pm If you are having pre-testing at your private physicians office: Please fax the results to: Attn: Elsa or Have pretesting done: • as soon as possible • within 2 weeks of surgery date 7 within 30 days of surgery date r Your child needs medical clearance from their pediatrician: Please fax the results to: Attn: Elsa or Have protesting done: • as soon as possible within 2 weeks of surgery date • within 30 days of surgery date Labs Only Please fax the results to: Attn: Elsa Have labs done: J as soon as possible u within 2 weeks of surgery date u within 30 days of surgery date or EFTA00285472 u You DO NOT need pre-testing f You are having Ambulatory Surgery, which means you will be going home after your surgery. You MUST have someone escort you home. Please ask a friend or family member to accompany you home. If you do not have an escort the surgery will be CANCELED. You are DAS, which means you are staying overnight in the hospital. r Please review the following: 1. Wear loose clothing for surgery 2. DO NOT wear any jewelry 3. REMOVE nail polish 4. Please shower normally the night before or morning of surgery. 5. Avoid using lotions, powders, and perfumes the night before and day of surgery DO NOT have anything to eat or drink after midnight the night before your operation. NO Breakfast. *This means NO water, coffee, tea, juice, milk, and chewing gum. If you take any prescribed medication, discuss them with the doctor before surgery.' IF you must take medications In the morning, you may do so with a Sip _of water. Please discuss these medications with the doctor before surgety,' DO NOT take any aspirins or aspirin-containing products for a period of 1-2 weeks prior to your surgery. *For pain relief use Tylenol ONLY during the two weeks before and after surgery.' if you are on coumadin or other blood-thinning medications please discuss them with Dr. Ting, to determine when to stop these medications/ EFTA00285473 Surgery Locations: On the day of your surgery please arrive 2 hours before your surgery time and go to: Ambulatory Surgery Unit Guggenheim Pavilion 1468 Madison Ave. (100th St.) 2nd fl New York, NY 10029 212-241-7778 -OR- 1190 5th Ave. 2nd fl New York, NY 10029 212-241-7778 y ) On the day of your surgery please arrive 1 hour before your surgery time and go to: Mount Sinai Surgical Associates Ambulatory Surgery 5 East 98th St 14th fl. (double doors) New York, NY 10029 212-241-0082 u On the day of your surgery please arrive 2 hours before your surgery time and go to: Mount Sinai Beth Israel 16th Street & 1st Avenue 1st, Admitting department in the lobby New York, NY 10025 (212) 212-420-4557 (The OR nurses will call you the day before surgery between 2-5pin to tell you what time to go to the hospital and other important information. If you surgery is scheduled for a Monday, the nurse will call you the Feiday before. If like you may call them the day before your surgery, after 3pm at the number above) a On the day of your surgery please arrive 2 hours before your surgery time and go to: Staten Island University Hospital 475 Seaview Ave. Staten Island, NY 10305 (718) 226-9000 EFTA00285474 S Patient: 4t-Xt retli The Mount Sinai Hospital 5 East 98th Street, 14th Floor, Mount Sinai New York, New York 10029 PLEASE FAX BACK WITH RESULTS TO ELSA OR ALICIA and PRE - PROCEDURE HISTORY & PHYSICAL EXAMINATION TELEPHONE: 212-241-4278 or 212-241-8512 PATIENT HISTORY Allereles Proposed Procedure(s): Chief Complaint/History of Present Illness: Medications / Herbals Past Medical History: Past Surgical History: Social/Occupation History: Substance Use: Tobacco: Alcohol: Other: Last Menstrual Period: PHYSICAL EXAMINATION Physiologic Data Head/Eyes/Ears/Nose/Throat/Airway: Cardiovascular: Pulmonary: Abdominal: Extremities: Neurological: Height: an Weight: kg BP: mmHg Pulse: /min Resp: /min Temp: •C ME Does this patient have bleeding tendency? O us O No Vinconlycin Justification: 08. lactam Allergy C1044105 Patient °toner are Farley a MRSA In Patient CP MA Prevalence can't Wound Care ASSESSMENT & PLAN Name: Dictation II: Signature: Date: Time: IMMEDIATE PREOPERATIVE REASSESSMENT I have reviewed the prior evaluation documented above of the Epic completed within the last 30 days. I have re-examined and re-evaluated the patient immediately prior tot e procedure and, unless otherwise indicated below, have found no significant changes in the patient's condition. Q Significant change has been documented in the Medical Record Name: Dictation g: Signature: Date: Time: Form N MR-212 (Rev. 20/14) Page 1 oil EFTA00285475 The Mount Sinai Hospital NY, NY Admission Test Order Sheet Patent Name kl.,p5+ Doe:: Meg WM% Illetlaul gala n t J 42-Q-Pre,t1 DI lac i5S Patent Address 1351 Flit Tet No. Admtstion Date Physician's Name Height it n. We•Ohl: os TECHNICIAN: Chock when completed PHYSICIAN Chock II requested TEST EKG -6 Tests" Blood Chemistry Only (Glucose. BUNS Electrolytes) Ll Medical Admissions For Me, PY. Na as NU Services (includes "6 tests", patient monitomg (7) + trio acid) n Surgical Admissions For all other services (Includes "6 tests", patient monitoring (7) Cry) p Complete Blood Count Urinalysis PT K PTT Type and Cross-Match K Chest X-ray (PA) Other Chest X-ray (og- lateral, etc) Please indicate: Pro-Operative History d Physical er lesta:* On the specific request of an admitting physician. additional tests can be performed on the ► below) same speb-men drawn for the new admission tests. The additional tests will be completed cn a routine basis. Please PRINT below those tests you wish to order. OTHER HEMATOLOGICAL TESTI3: OTHER CHEMISTRY TESTS: e of Physician Blood (kawn By Ca [4)3 1 +" Date • Mease not* this Hematology. Chantey and talcaotology test testa are available on the Lacsatory info/mew System. Results can be rehieyed by teiminat inquiry at by caang the LABCRATCHT INFORMATtal INGLORT 06.SK. xntlASS Othee canaries we be added to the Labotatoty Inkomation System in me nut hen. Psteasr db not or another specimen for rebut Wang  ”Du do not see yo ors on US You may inputs %%tether the test has been psnormed by tang r4U/SS. Some lab:ea:stet are not on US and the results cannot be retneved by anal access Erne/Date Blood Drawn I> I 4,5 (REV. 2/113) EFTA00285476