PRE-OPERATIVEHEALTHQUESTIONNAIRE for SILVERMANEYECARE
Patient Name: DOB Today's Date: ______
HAVE YOU EVER HAD:
Y ____ N Heart Trouble
Y ____ N Asthma or Breathing Problems**
Y ____ N Diabetes **
Y ____ N Epilepsy or Convulsions or Stroke
Y ____ N Bleeding Tendency, include meds that cause blood thinning like aspirin, fish oil, coumadin
(warfarin), plavix, vitamin E, ginkgo biloba **
Y ____ N Jaundice, Hepatitis or Liver Problems
Y ____ N Kidney Disease or Urinary Tract Infection
Y ____ N _____ Chronic Back Problems
Y N _____ Rheumatoid Inflammatory Joint Arthritis, Sjogrens's Disease or Lupus **
Y ____ N Anxiety Problems
Y ____ N Abnormal Chest X-ray
Y ____ N Abnormal EKG
Y ____ N A Bad Reaction to Local/General Anesthesia - Include Name of Medication
Y ____ N Allergies or Reactions to Drugs
If Positive allergies to any medications including aspirin - Please List:
DO YOU:
Y ____ N Wear Contact Lenses
Y ____ N Wear a Hearing Aid
Y ____ N Have Dentures, Caps or Bridges? If so, Circle
Y ____ N Smoke? If so, How Much?
Y ____ N Drink Alcohol? Is so, How Much Per Day?
Y ____ N Do you have an Automatic Internal Defibrillator? **
Y ____ N Current or ANY past use of Flomax, Tamsulosin, Terozin, Cardura, Hytrin or any other
prostate related medications: Write medications name if not listed:
Y ____ N Do you have any issues lying flat for 1A hr even if your head is supported
And your knees are bent? **
Y ____ N Take Prescription Medications? Please List All Medications Below. Circle your
Prostate related medication if known.
______
______
Patient Name and Signature ______
______
Witness Date
Silver-man EyeCare - 475 Tuckahoe Road -Yonkers- New York -(914)961-2700
Cataract Surgery/Phacoemulsification (Phaco) Consent Form
Phacoemulsification is the method Dr. Silverman uses to remove a cataract from your eye, which is a clouding of the eye's naturally clear lens. This cloudiness that develops can then interfere with light passing clearly through the pupil to the retinal surface. This makes images look blurred, cloudy or distorted. Having a cataract can be compared to looking at the world through a foggy window.
Phacoemulsification is not a laser procedure. In phacoemulsification, an ultrasonic oscillating probe is inserted into the eye through a small incision. The probe breaks up the center of the lens into tiny pieces. The fragments of the lens are then suctioned from the eye and removed. Dr. Silverman performs her cataract surgery through a small incision in order to more safely remove the tiny pieces of cataract from the eye. It also allows her to insert a smaller foldable intraocular lens implant, without having to significantly enlarge the initial incision. The implant, also known as an IOL, is usually made of acrylic material, and is permanently placed in your eye. This implant helps the light coming into the eye to focus on the retina so that you can see more clearly after surgery-While cataract surgery usually goes well and uneventful, it is still surgery. And, as with any surgery, complications are possible, including, but not limited to infection, excessive swelling or bleeding, glaucoma, the need for secondary surgery and even permanent loss of vision. There may also be specific preexisting eye conditions in your eyes that make your surgery or potential visual outcome more risky and with less ultimate visual potential. These may include preexisting glaucoma, macular degeneration, retinal problems, double vision, dry eye and even eyelid drooping. Your individual visual expectations from the surgery should be reasonable since Dr.
Silverman has explained your potential risks, benefits and alternatives to the cataract surgery.
* * * * * *
Dr. Silverman has explained to me that I can choose to remain with my cataract and accept the level of vision that I currently have. I was also given the opportunity to ask questions. She has also explained that the new lens implant power, while measured for accuracy, is still an estimate and can have some degree of inaccuracy.
l have decided to proceed with cataract surgery and a single vision lens implant of the:
RIGHT LEFT EYE
I have discussed and read the details and additional risks and benefits of an Advanced Technology lens and I choose this option for my lens implant.
MULTIFOCAL RESTOR lens Crystalens ACCOMMODATIVE LENS TORIC ASTIGMATIC LENS
RIGHT LEFT EYE
Name Signature Date
Witness Signature Date
Name
Physician: BONNIE SILVERMAN Signature Date
Silverman EyeCare, Bonnie S. Silverman, M.D., 475 Tuckahoe Road, Yonkers, N.Y. (914)961-2700 Tel
Form #49 St. John's Riverside Hospital
Andrus Pavilion v Park Care Pavilions
Yonkers, New York
Dobbs Ferry Pavilion
Dobbs Ferry, New York
CONSENT TO OPERATION/SPECIAL TREATMENT OR PROCEDURES
I hereby authorize Dr. Bonnie S. Silverman, associates or assistants of his/her choice at St. John’s Riverside Hospital (SJRH) to perform upon ______the following operation/s and/or procedure/s Cataract extraction with intraocular lens implant ______R L eye _
Dr. Bonnie S. Silverman has fully explained to me the nature and purpose of the
operation/procedure and has also informed me of expected benefit, risks and possible alternatives that may arise with the proposed treatment including no treatment. I understand that unforeseen conditions may arise which necessitate procedures different from those contemplated. I therefore request and consent to the performance of additional operations and procedures which the above named physician, his/her associates, or assistants may consider necessary.
(Check if applicable) I consent to the presence of a manufacturer's technical support representative
(a non-hospital employee) as necessary or advisable during this procedure.
I understand that this representative will not be permitted to enter a sterile field and will not
participate in the operative procedure.
I have been given an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the operation or procedure.
Patient's/Relative or Guardian's Signature (state Relationship) Printed Name Date
Witness Signature Printed Name Date
Interpreter's Signature Printed Name Date
I hereby certify that I have explained the nature, purpose, benefits, risks of and alternative to, the proposed procedure/operation, have offered to answer any questions and have fully answered all such questions. I believe that the patient/relative/guardian fully understands what I have explained and answered.
Bonnie S. Silverman
Physician's Signature Printed Name Date
Patient/Proxy/Legal Guardian/Relative Refuses Transfusion of Blood/Blood Products.
Signature Date Witness Date
Print Name Print Name
If the patient/proxy/legal guardian/relative refuses a blood transfusion, a "Refusal to Permit Blood Transfusion Form" must be completed and such refusal must be attached to this consent.
TURNOVER •»
Bonnie S. Silverman, M.D.
Silverman EyeCare- Practice of Ophthalmology 475 Tuckahoe Road, Yonkers, N.Y. Tel(914) 961-2700 Fax(914) 961-0369
Name of Patient: Date of Procedure
Planned procedure: Cataract extraction lens implant R L Eye
Other:
Location: St. Johns Riverside Hospital (SJH) Eye Surgery Center of Westchester
Tel ((914)964-4444 Fax 914-964-4979 Tel (914)-576-9600 Fax (914) 576-6196
Dear Doctor
Thank you for seeing our mutual patient. The proposed cataract surgery is minimally invasive, performed under topical anesthesia, and is typically in duration of less than 1A hour.
The facility requires the patient to have a history, physical and blood testing (SMA 6 and CBC) completed within 30 days of the date of surgery and an EKG within 6 months of the date of surgery. EKG's reports and readings must be included. No CXR is required unless you feel the patient needs it, but please state this in your clearance note. Obviously, if you feel a patient needs more updated labs (ie: diabetics) the additional testing is at your discretion. Basic bloods required are SMA 6 and CBC with diff.
Anticoagulants: We no longer require anticoagulants to be stopped before clear cornea cataract surgery. A coagulation profile should only be done if you feel your patient needs an update. It is confusing to the hospital and amb surg ctr to receive highly abn. bloods, like prolonged PT's when clearing patients. Please note that there is still some risk of bleeding, even with an ASA qd and our patients dislike any redness in the conjunctiva after surgery. So advise your patients accordingly regarding their use of these medications in advance of surgery. (ASA, Coumadin, Plavix, Vit E, Advil, etc)
Alpha adrenergic drugs: Please bring any current or previous use of "prostate medications" such as Flomax, Hytrin, and Cardura to our attention before the surgery.
Defibrillators: Please let us know in advance if your patient has one and what type.
Diabetics: If applicable, please advise your patients regarding modifications in the administration of their medications pre and post surgery.
We are enclosing the history and physical form to be used. This form must be faxed to the OR facility (fax listed above) no less than three days before surgery. Thank you for your cooperation in getting our mutual patient safely through their procedure.
Sincerely,
In addition, Please fax all
Bonnie S. Silverman, M.D. clearance forms to our
office.
Fax #: (914) 961-0369
ST. JOHN'S RIVERSIDE HOSPITAL
ANDRUS PAVILION
967 North Broadway. Yonkers, NY 10701
PREOPERATIVE MEDICAL
CONSULTATION AND
CLEARANCE
Patient's Name (Print): Surgeon: ______
Date:
Proposed Surgical Procedure:
Type of Anesthesia: ______
Medical History: ______
Patient’s ______Weight ______Height ______B/P ______Pulse
Heart: ______Medications ______
Lungs: ______
Neck: ______
Allergies: ______
______
Pre-Admission Testing Review: ______
______
______
______
In my opinion, there are no contraindications to the proposed surgery and anesthesia.
Comments/Recommendations: ______
______
Labs will be accepted if the laboratories are state accredited
EKG recommended to be done in the St. John's Riverside Hospital. When it is done outside of the St. John's Riverside Hospital, only normal 12 lead EKG with official reading will be accepted. Abnormal EKG may not be acceptable at the discretion of Anesthesiologists in St. John's Riverside Hospital. One long strip, or poor copies are not acceptable.
Cardiology consults: Strongly recommend using a Cardiologist on the staff of St. John's Riverside Hospital unless reasonable explanation informed prior to surgery. All major vascular surgery mandates cardiology consult.
Results of pre-admission testing must be available to hospital 24 hours prior to admission.
Phone
Address:
M.D.
Silverman Eye Care
Bonnie S. Silverman, M.D.
475 Tuckahoe Road Phone: (914)961-2700
Yonkers, NY 10710 Fax: (914)961-0369
PRACTICE OF OPHTHALMOLOGY INSTRUCTIONS BEFORE YOUR SURGERY
• Date of Surgery
• Post operative appointment
• You MUST be seen by your primary physician (usually your general
internist) no later than TWO weeks prior to your surgery. It is then
YOUR RESPONSIBILITY to contact your doctor one week prior to
the surgery to confirm that all necessary results and paperwork have
been forwarded to the appropriate facility. Significant delays in
paperwork can unfortunately cause unnecessary last minute
cancellations of surgery.
• St. John's Hospital (914)964-4979 fax
• Eye Surgery Center of Westchester (914) 576-7875 fax
• REMEMBER: Do not eat or drink anything after midnight the
evening before surgery, wear loose clothing and leave your valuables
at home.
• PLEASE arrive at the hospital on time for your surgery. The
hospital or surgery center will call you the day prior to the surgery
with your expected arrival time. If you do not hear from them by
3:00 P.M. the day before surgery, please feel free to call the
facility and not our office, since we will not have your start time
information.
• St. John's Riverside Hospital (914) 964-4234 ph
• Eye Surgery Center of Westchester (914)576-9600 ph
• RELAX. Do not hesitate to call if you have any additional questions
regarding your upcoming surgery.
Directions TO ST. JOHN'S RIVERSIDE HOSPITAL
967 North Broadway, Yonkers, NY 10701 914.964-4912
Directions from Long Inland
Whitestone Bridge to Hutchinson River Parkway North to Cross County Parkway West. Take Cross County Parkway West to Saw Mill River Parkway North (signs say Albany). Take Saw Mill River Parkway to Executive Boulevard to the end. Turn Left onto North Broadway. At the second traffic light, turn right to St. Johns Riverside Hospital,
Directions from New York City
West side Highway (Henry Hudson Parkway) to Saw mill River
Parkway North to Executive Boulevard exit (right hand exit). Follow
Executive Boulevard to the end. Turn left onto North Broadway. At
the second traffic light, turn right to St. Johns Riverside Hospital.
Or
East Side Highway to Third Avenue Bridge to Major Deegan
Expressway (87 North). Exit at Cross County Parkway west. Take
Cross County Parkway West to the Saw Mill /River Parkway North
and follow as above.
Directions from Northern Areas
Taconic State Parkway or New York State Thruway (87) South to Saw Mill River Parkway South. Take the Saw Mill South to Executive boulevard exit (right hand exit). Follow Executive Boulevard to end. Turn left onto North Broadway. At the second traffic light, turn right to St. Johns.
Directions from New Jersey
Take the George Washington Bridge to Henry Hudson Parkway
North to Saw mill River Parkway and follow as above.
Or
Take the Tappan Zee Bridge and the New York State Thruway (87)
South to the Saw mill River Parkway South and follow as above.
Trains
Hudson River Line of Metro North to Yonkers Station. Taxi to St.
Johns.
Bus
Call BeeLine Bus Service for convenient schedule and travel
information: 914-682-2020.