Please complete the following fields listed below and give this form to the surgeon's secretary once it has been completed
- Date of Birth
- Telephone number
- Sign the signature line
This form explains your rights and responsibilities as a patient at the University of Maryland Medical Center.
This questionnaire will help your anesthesia team determine what if any preoperative work up will be needed prior to your surgery and help them gather all available medical information about you.
Adverse Events and Infections: How to Prevent Complications from Your Surgery
Read before you sign! This applies to everything, especially consents. Be sure all information is correct! On the day of surgery, Tell the doctor and nurse your name, birthday and on which part of your body you are having surgery.
If your surgery is on your spine, or either the left or right side of your body, EXPECT that staff will confirm the location with you and will MARK that side. Examples are left knee or right ear. It can also be your spine, or the left or right side of your head.
SPEAK UP if you think any information is wrong or not exact and completely correct. We want your surgery to go exactly as planned!
UMMC Takes Infection Prevention Very Seriously
Here Are Things You Can Do:
- If your doctor gave you Mupirocin nose drops, use them as directed.
- If you doctor gave you a special soap known as Chlorhexidine, take two showers using it. Take the first shower the night before your surgery.
- Everyone must wash their hands prior to giving you care. This includes doctors, nurses, your family and visitors. They may use the alcohol gel at the entrance to your room.
- It is OKAY to ask anyone who touches you if they washed their hands.
- Visitors who are sick, even with just a cold, SHOULD NOT VISIT.
- If you have a catheter to drain your urine after surgery, the bag should never be higher than the level of your thigh
Location and Contact Info
22 S Greene St
Seventh Floor, North Elevators
Baltimore, MD 21201