CONFIRMATION OF PREOPERATIVE PATIENT TEACHING:

1. I have been instructed and fully understand the preoperative instructions.

2. I have arranged for a responsible person to accompany me from the hospital after discharge.

Person's Telephone
Name ________________________________________ Number: _________________________

3. I last ate food at ______________________ AM/PM.

4. I last drank liquids (including water) at ______________________ AM/PM.

5. I have / have not, taken medications / drugs during the last 24 hours.
If taken:

Name of Drug/Medication Dosage Time Taken

6. I will notify my physician immediately if any unusual bleeding, respiratory problems or acute pain
occurs after my discharge from the hospital.

7. I understand that driving a car and drinking alcoholic beverages less than 24 hours after general
anesthesia is prohibited.

8. I understand that if a condition arises during my surgery, and the operating physician feels that
admission to the hospital is best for my recovery, then he may admit me as an inpatient following
my surgery.

9. I understand and agree to receiving a post-operative phone call after discharge from the hospital -
Telephone Number ___________________________________

PATIENT SIGNATURE DATE

WITNESS SIGNATURE AND TITLE DATE

Patient Identification

Sutter Medical Center, Sacramento

A Sutter Health Affiliate

Pre-op Teaching Confirmation-ACU

00512 (2/6/06) Original - Chart Copy - Patient FLOWSHEET