Patient Name: ____________________________________________
Surgery Date: ____________________________________________
Operative Procedure: ______________________________________
ICD 9 Diagnostic Code: ____________________________________
Medical Clearance? No Yes, with __________________
PRE SURGICAL TESTING: MUST BE COMPLETED a minimum of 7-10 days before scheduled surgery date. Form to be completed by surgeon. Please check all categories below which apply to patient. DISEASE PROCESS MODIFIERS: Prior EKG over age 40 good for 3 months History of Diabetes: (FBS, POTASSIUM, EKG) 250.00 HISTORY OF CARDIAC DISEASE: Prior EKG good for 6 mos., diabetic patient 3 months Coronary Artery Disease: (CBC, CREATININE, POTASSIUM, EKG) 414.00 Hypertension: (CBC, CREATININE, POTASSIUM, EKG) 401.9 Renal: (CBC, CREATININE, POTASSIUM, EKG) 404.00 Angina: (CBC, CREATININE, POTASSIUM, EKG) 413.9 Myocardial Infarction: (CBC, CREATININE, POTASSIUM, EKG) 412 Diuretics: (CBC, CREATININE, POTASSIUM, EKG) 276.0 HISTORY OF PULMONARY DISEASE: Prior EKG good for 6 mos., diabetic patient 3 months COPD: (POTASSIUM, EKG, CXR) 491.21 CHF: (POTASSIUM, EKG, CXR) 428.0 LVF w/ pulmonary edema: (POTASSIUM EKG, CXR) 428.1 Emphysema: (POTASSIUM, EKG, CXR) 491.20 Bronchitis: (POTASSIUM, EKG, CXR) 491.21 Asthma: If acute at PSS (POTASSIUM, EKG, CXR) 415.19 HISTORY OF LIVER DISEASE: Chronic, long term : (CBC, CREATININE, LFT, PT, PTT) 573.9 ETOH Abuse: (CBC, CREATININE, LFT, PT, PTT) 571.3 Hepatitis: (CBC, CREATININE, LFT, PT, PTT) 573.3 Liver failure: (CBC, CREATININE, LFT, PT, PTT) 571.9 CATARACT CASES: If MAC: General Anes or non-cataract ophthalmology cases, default to disease process modifiers Diabetic: (FBS, POTASSIUM) 250.00 Renal History: (POTASSIUM) 404.00 Cardiac History: (POTASSIUM) 414.00
OTHER FACTORS: Known Bleeding Disorder: (CBC, PT, PTT, BLEEDING TIME) 286.9 Leukemia: (CBC, PT, PTT) 208.90 Cancer: (code specific): (CBC) ____________ All Menstr. Females, all GYN procedures: (BHCG) V72.40 (H&H) V78.0 MEDICATION MODIFIERS: Coumadin: (PT/INR) 286.9 Digoxin: (CREATININE, POTASSIUM, DIGOXIN LEVEL) E942.1 Steroids: Other: ____________________________________________ Copies to: _________________________________________ Surgeon Signature: _________________________________ DEAR PATIENT: Please plan to spend about 45 minutes for your pre-operative visit. Screenings are done daily Monday through Friday between the hours of 9:00 a.m. and 2:00 p.m. We welcome the opportunity to participate in your medical care. We depend on your surgeon to evaluate your health and order the appropriate studies. We depend on YOU to provide accurate health screening information on this form. PLEASE COMPLETE THE ATTACHED SURVEY BEFORE YOU ARRIVE. The Staff of Pocono Ambulatory Surgery Center. ASC forms Pre OP Labs, jm 06/99,7/99,3/00,9/01,5/02,3/03,9/04,6/05,1/06,4/07,5/07, 05/08, 11/09, 06/11Right Protected
CHEMICALS AND LIFESCIENCE Winter 2006 QUARTERLY The Intellectual Property Group Introduction This quarterly newsletter from the Intellectual Property (“IP”) Group at Walker Morris intends to keep the IP Group’s clients and friends updated on some key developments in the legal environment affecting chemicals, pharmaceuticals, biotechnology and medical devices bu
Javelin Pharmaceuticals Signs Commercial Supply Agreement with Precision Pharma Services New York-Based Contract Manufacturer to Supply Dyloject(TM) for Launch in Europe CAMBRIDGE, Mass., Feb 26, 2007 (BUSINESS WIRE) -- Javelin Pharmaceuticals, Inc. (AMEX: JAV), a leading developer of novel products for pain control, today announced it has signed a Commercial Supply Agreement with Precis