Admission History. Please indicate medications with dose & frequency on separate Home Medication List If no home medications, please check HERE
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1 Admission History Manchester Road, Suite 103 St. Louis, MO phone: secure fax: Prior to your scheduled procedure, please complete and fax, mail or have available when the nurses contact you from the Surgery Center to discuss your medical history. Patient Name: Date of Service: Date of Birth: Sex: M F Height: Weight: Surgeon: Scheduled Procedure: List of Past Surgeries: Drug Allergies: Alcohol Use: Tobacco Use: Please indicate medications with dose & frequency on separate Home Medication List If no home medications, please check HERE DO YOU HAVE ANY (check which applies): Heart Problems (MVP, murmurs, heart attack, CHF, A-fib, irregular rhythm) History of Cancer/ Specify: Pacemaker/AICD High blood pressure High cholesterol Sleep apnea/cpap Respiratory disease (asthma, chronic bronchitis, emphysema, COPD) Diabetes Thyroid Disease Glaucoma History of seizures History of strokes/tia Infectious Disease (HIV, hepatitis, shingles, TB) Kidney or liver problems History of motion sickness History of post-operative nausea or vomiting Family history of anesthesia problems (Does anyone in your family run a high temp with anesthesia?) Acid reflux or hiatal hernia Bleeding or clotting abnormalities Panic attacks, anxiety or depression Neurologenic Disease (Alzheimer's, Parkinson's) Other medical or surgical history: Form #101 Revised Jan. 2013
2 12990 Manchester Road, Suite 103 St. Louis, MO phone: secure fax: This document is required to be on-file at the St. Louis Eye Surgery & Laser Center PRIOR to surgery Procedure Date: Surgeon: 1 I, am aware that because I am scheduled to receive anethesia services, St. Louis Eye Surgery & Laser Center (SLESLC) requires the following: 1. I can NOT drive myself home after my procedure. 2. I must have a responsible adult present at the center during my procedure. This person must receive and sign instructions and escort me home. 3. I should have a responsible adult available for 24 hours after the procedure. I understand that it is my responsibility to make these arrangements before arriving at SLESLC for my procedure. I understand that if these arrangements are not made prior to my arrival, my procedure may be cancelled. Patient/POA/Relative/Guardian - Signature Relationship to Patient Date 2 I, give permission for personnel of St. Louis Eye Surgery & Laser Center (SLESLC) to leave messages on the voic /answering machine of the telephone number(s) I have provided below as my contact number(s). SLESLC will call before surgery to pre-register and obtain a brief medical history. I understand that SLESLC may leave information on a message regarding pre-operative instructions for my procedure and a postoperative call to check my condition. SLESLC may also contact the individual(s) listed below to obtain my health information. Patient/POA/Relative/Guardian - Signature Relationship to Patient Date Home Phone Cell Phone Work Phone Contact Person(s) Phone 3 I have received the SLESLC patient information booklet prior to my date of service and made particular note of information addressing my rights and responsibilities as a patient, information regarding a living will or advanced care directive, as well as information regarding physician ownership in SLESLC. Patient/POA/Relative/Guardian - Signature Relationship to Patient Date Form #102 Revised Jan. 2013
3 Home Medication List Manchester Road, Suite 103 St. Louis, MO phone: secure fax: Patient Name: Medication Name Dose Frequency Reason Taken New Medications (To be completed by Surgery Center staff) I have received my post-operative eye drop regime/kit from my physician's office Responsible Party Signature RN Signature Form #103 Revised Jan. 2013
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5 St. Louis Eye Surgery & Laser Center Surgery Information Surgery Date: Arrival Time: Surgery Time: Hours of Operation Monday - Friday, 6:00 am - 4:00 pm Turnaround from West to East Manchester (left lane) I-64/40 I-270 N Manchester Road Fox Jewelers West County Center Ballas Road From St. Louis/Clayton/Creve Coeur Take I-270 to Manchester Road West Exit. Travel one mile west to the Manchester Road East turnaround. Exit Left. Travel 1/2 mile and turn right, just beyond Fox Jewelers into the The St. Louis Eye Surgery & Laser Center located in the Eye and Surgery Center's building. From Chesterfield Take Hwy. 40/64 to Hwy. 141 (South). Turn left (East) on Manchester Road and travel 2.8 miles. Turn right just beyond Fox Jewelers into The St. Louis Eye Surgery & Laser Center located in the Eye and Surgery Center's building. From Fenton Take Hwy. 270 rth to Manchester Road West Exit. Travel one mile west to the Manchester Road East turnaround. Exit left. Travel 1/2 mile and turn right, just beyond Fox Jewelers into The St. Louis Eye Surgery & Laser Center located in the Eye and Surgery Center's building. Form #93 Revised Oct. 2012
6 THE RETINA INSTITUTE Hotel Information - St. Louis Eye Surgery & Laser Center Drury Inn Creve Coeur Olive Blvd Rate: $$$ Form #94d Revised Oct. 2012
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POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
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