Heritage Surgery Center

Heritage Surgery Center
Rudolf Churner, M.D. • Sanjay Patel, M.D.
1501 Redbud Blvd.
McKinney, TX 75069
(972) 548-0771
Patient Name: ____________________________________ Eye: ______________
Instructions Before Surgery - Please check in for surgery at the door directly
to the right of the main entrance.
SURGERY DATE/TIME: __________________________________
1.
PRE-OP EYELID WASHES: 3 days before your surgery, gently wash eyelids thoroughly with a mixture
of 1/2 water and 1/2 baby shampoo for 2 minutes, 2-3 times a day. Rinse well.
2.
FOOD: DO NOT eat or drink after midnight the night before your surgery unless otherwise instructed.
3.
BATHING: Bathe or shower and wash your hair as you normally would. NO facial make-up. When
brushing your teeth, do not swallow the water.
4.
CLOTHING: Wear comfortable clothing. NO pantyhose. NO jewelry or valuables. You may wear your
Rudolf Churner,
M.D.
- Sanjay
M.D. Please do not wear contact lenses.
dentures, hearing
aids and
glasses
day Patel,
of surgery.
Heritage Surgery Center
1501 Redbud Blvd.
McKinney,
TX 75069
MEDICATIONS: Medications
allowed
the morning of surgery include: blood pressure, heart,
(972)
548-0771
Surgery
Center
Parkinson’s andHeritage
anti-seizure.
Take
with a small sip of water. USE YOUR EYE DROPS MORNING OF
Heritage
Surgery
Center
Rudolf
Churner,
M.D.
Sanjay
Patel,
M.D.
SURGERY.
Patient Name:_______________________________________________Right
Eye Left Eye
5.
1501 Redbud Blvd.
Rudolf Churner, M.D. - Sanjay Patel, M.D.
McKinney,
TX 75069
TRANSPORTATION:
A
friend
orAfter
relativeSurgery
will need to drive you to and from the office day of surgery.
1501
Redbud Blvd.
Instructions
(972) 548-0771
McKinney, TX 75069
They will need to remain
on the premises while you are in surgery. Plan on being here 2-3 hours. Limit
• You
may be up and around. (972)
You 548-0771
may resume normal activities
reading, writing
Patient
Name:_______________________________________________Right
Eyesuch
LeftasEye
2
visitors
per
Patient.
You
will
need
someone
to
stay
with
you for the first 24 hours after surgery.
and
watching
television
.
Patient Name:_______________________________________________Right Eye Left Eye
6.
Instructions After Surgery
7.
8.
9.
10.
drops
be
continued
You
will glasses,
be given
post-op instructions after surgery and
•AllKeep
yourwill
operated
eye protectedafter
while surgery.
outside
by the
shield,
or sunglasses.
Instructions
After
Surgery
• You may be up and around. You may resume normal activities such as reading, writing
one
day
post-op
andYou
watching
television
. visit.
may
be
up and around.
You
may resume
normal activities
such Tape
as reading,
writingin your post-op kit.
your
shield
while
sleeping
or napping
for 7 days.
provided
• • Wear
and watching television.
• Keep your operated eye protected while outside by the shield, glasses, or sunglasses.
We are happy
to be ofavoid
service toanything
you and
hope this
will beeye.
of assistance in making your surgery
oroperated
bath normally,
irritating
the operated
• • Shower
Keep your
eye protected whilegetting
outside by the shield,
glasses, orinsunglasses.
Wear your shieldconvenient.
while sleeping or napping for 7 days. Tape provided in your post-op kit.
• experience
Wear
your shield
whileover
sleeping
7 days.
in your
kit.
• • No
lifting
anything
20 orlbsnapping
for 1 for
week;
NoTape
eyeprovided
make-up
for post-op
3 weeks.
• Shower or bath normally, avoid getting anything irritating in the operated eye.
on your
Please contact the Heritage Surgery Center at 972-548-0771, if you have any further questions.
• Shower or bath normally, avoid getting anything irritating in the operated eye.
ABSOLUTELY,
NO
lifting anything over
20 RUBBING,
lbs for 1 week;BLOTTING,
No eye make-upOR
for 3WIPING
weeks. THE
•• No
• No lifting anything over 20 lbs for 1 week; No eye make-up for 3 weeks.
•• ABSOLUTELY,
NOdrops,
RUBBING,
OR WIPING
THE
EYE.
When instilling
wait BLOTTING,
5 minutes between
each
one
• ABSOLUTELY, NO RUBBING, BLOTTING, OR WIPING THE EYE.
• When instilling drops, wait 5 minutes between each one
• When instilling drops, wait 5 minutes between each one
One Day Post-Op Appointment:
EYE.
DROPS AND INSTRUCTIONS: WAIT 5 MINUTES BETWEEN DROPS.
VIGAMOX (Antibiotic)
VIGAMOX
(Antibiotic)
VIGAMOX
Use one(Antibiotic)
drop 3 times a day for 7 days, THEN STOP
VIGAMOX
Use one drop 3 times a day for 7 days, THEN STOP
Use one drop 3 times a day for 7 days, THEN STOP
Use one drop 3 times a day starting 3 days before surgery.
DUREZOL
DUREZOL
DUREZOL
DUREZOL
Use one drop 3 times a day1starting
month 3 days before surgery.
Use one drop 3 times a day for 1 month
Use one
times 3
a day
for 1amonth
Usedrop
one3 drop
times
day for
NEVANAC
NEVANAC
NEVANAC
Use one drop 3 times a day for 10 days, THEN STOP
Use one
drop 3 times a day for 10 days, THEN STOP
NEVANAC
Use one drop 3 times a day starting 3 days before surgery.
Use one drop 3 times a day for 10 days, THEN STOP
By
If If
you
have
increase
redness
or
in
please
call
signing,
you
acknowledge
the
above
and the
receipt
ofcall
the
you
haveany
any
increaseininpain
painor
or
redness
ordecrease
decrease
in vision,
vision,
please
972-548-0771.
972-548-0771.
HIPPA notice of privacy practices.
Patient’s
Signature:
Date: ___________________
If you
have any________________________________________
increase in pain or redness or decrease in vision, please call
H30311
H30311
972-548-0771.
Witness Signature: _________________________________________ Date: ___________________
H30311
H21363