Jess iting, iu 5 E. 98 Street, 14! fl. Ste. B ay % Department of Surgery New York, N¥ 10029 BAA Division of Plastic & Reconstructive Surgery Office Tol: Office Fax: ount © nal PRE-OPERATIVE INSTRUCTIONS Name of Patient: Loctein, Seflrey Name of Operation: Operation Date:(_) 4 (Sit 4 Operation Time: Span Am / Pm Arrival Time: _Aprn _ Am / Pm NOTE: YOU MUST FOLLOW THE INSTRUCTIONS OUTLINED NEXT TO ANY CHECKED BOXES BELOW. “a Call Elsa at ( option 1, the BUSINESS DAY before surgery, to confirm surgery time. Q You need pre-testing (blood tests, EKG, physical) Pre-testing will be done at Mount Sinai Hospital 10 Union Square East on 14" Street, Suite 3 B, Third floor. Date of Pre-testing: / / Time:__: am/pm Q If you are having pre-testing at your private physicians office: Please fax the results to: Attn: Elsa or Have pretesting done: 2 as soon as possible Q_ within 2 weeks of surgery date Q_ within 30 days of surgery date Your child needs medical clearance from their pediatrician: Please fax the results to: Attn: Elsa Po or Have pretesting done: Q as soon as possible within 2 weeks of surgery date Q within 30 days of surgery date a Labs Only Please fax the results to; Attn: Elsa PY or | Have labs done: Q as soon as possible a within 2 weeks of surgery date a within 30 days of surgery date EFTA00285472

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a You DO NOT need pre-testing ree 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. a You are DAS, which means you are staying overnight in the hospital. 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 Pp Please review the following: 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 surgery.” 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

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Surgery Locations: a 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. (100* St.) 24 fl New York, NY 10029 212-241-7778 -OR- 1190 5th Ave. 2d fl New York, NY 10029 212-241-7778 ~ 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 Q On the day of your surgery please arrive 2 hours before your surgery time and go to: Mount Sinai Beth Israel 16 Street & 1st Avenue 1*t, Admitting department in the lobby New York, NY 10025 (212) 212-420-4557 (The OR nurses will call you the day before surgery between 2-5pm to tell you what time to go to the hospital and other important information. {f you surgery is scheduled for a Monday, the nurse will call you the Friday 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

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The Mount Sinai Hospital 5 East 98" Street, 14" Floor, Mount PATIENT HISTORY Proposed Procedure{s): Chief Complaint/History of Present Illness: Past Medical History: Past Surgical History: Social/Occupation History: Substance Use: Tobacco: Last Menstrual Period: Sinai New York, New York 10029 ELSA OR ALICIA PRE - PROCEDURE HISTORY & ‘)RLEPHONE- PHYSICAL EXAMINATION 212-241-8512 212-241-4278 or Allergies Medications / Herbals PHYSICAL EXAMINATION Head/Eyes/Ears/Nose/Throat/Airway: Cardiovascular: Pulmonary: Abdorninal: Extremities: Neurological: Note: Does this patient have bleeding tendency? (_) ves CI No Temp: Height: Weight: BP: Pulse: Vancomycin Justification: OB-lactam Allergy © Dtalysis Patient © Long-Term Care Facility © MRSA in Patient O MASA Prevalence & Chronic Wound Care ASSESSMENT & PLAN Name: Dictation #: Signature: Date: Time; MEDI. PREOPERATIVE R ENT | have reviewed the prior evaluation documented above or the Epic have found no significant changes in the patient's condition. () Significant change has been documented in the Medical Record Name: Dictation #: Signature: completed within the last 30 days. | have re-examined and re-evaluated the patient immediately prior to the procedure and, unless otherwise indicated below, Date: Time: Form # MR-212 (Rev, 10/14) Page lofi EFTA00285475

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= “VA The Mount Sinai Hospital NY, NY Kpstei oO; J ere y Admission Test Order Sheet "6 Tests” Blood Chemistry Only (Glucose, BUN & Electrolytes) Medical Admissions For Me, PY, ND, GS, NU services {includes "6 tests", patient monitoring (7) + uric acid) Surgical Admissions For all other services {includes “6 tests”, patient monitonng (7) OOOO 000 Type and Cross-Match OOO im Chest X-ray (PA) Other Chest X-ray (eg. lateral, etc). Please indicate: Pre-Operative History & Physical OO or tests:* On the specitic request of an admitting physician, additional tests can be performed on the below) same specimen drawn for the new admission tests. The additional tests will be completed on a routine basis. Please PRINT below those tests you wish to order, OTHER HEMATOLOGICAL TESTS: OTHER CHEMISTRY TESTS: Blood Drawn By Oate Time/Date Blood Drawn * Please note that Hematology, Chemisty ang Microbiology lest resuits are avaiable on the Laboratory information System, Results canbe retrieved by terminal inquity of by calling the LABORATORY INFORMATION INQUIRY DESK, x-4LA8S. Other laboratories wil be added to the Laboratory information System in the neat future, Please do not order another specimen for repeat testing if you do not see your order on LIS. You may ingure whather the test has been pertormed by calling x-4LABS, Some laboratories are not on LIS and the results cannot De retrieved by terminal access. 1-4-5 (REV. 2/03) EFTA00285476