Surgery Day Checklist Patient Name: Date Of Procedure:
Type of Procedure:
Pre Procedure Checklist: FRONT DESK CHECK IN Consent form explained, signed and witnessed Do you have any insurance? Yes No (if yes take two copies of insurance card) Fee Explanation, signed and witnessed _____ Lead Source confirmed
TECHNICIAN CHECK IN
PUNCTAL PLUGS INSERTED?
Topography (if not in chart) ď ą YES Refraction re-checked ď ą NO Wavescans (take 3 if applicable) Pupil size Hair cover, gown & booties Any known allergies to any medications? Valium Offered Yes Refused Patient Initials___________ Envelope Number_______ Quantity Time Given___________ Drops given Proparacaine time given: Ofloxacin time given: Doctor-procedure explained to patient (have Doctor initial this area) Carry chart to laser room & check key card information Post-Op Procedure Checklist: TECHNICIAN CHECK OUT Post-op instructions given Post-op bag given Check to make sure one day post-op appointment is made Doctor-flap checked BEFORE patient leaves _____ Faxed treatment to co-managing doctor