Headings
Procedure discussed · Medical history · Medications and allergies · Examination · Risks and alternatives discussed · Pre-operative instructions · Consent · Plan
When to use it
Use this once the client has chosen a specific surgery and needs to be cleared and consented. It is narrower than a new patient consultation and focuses on fitness for surgery, risks and preparation. Surgeons and surgical coordinators use it in the weeks before the operation date.
Example
Fictional example
Procedure discussed
B.N., 58F. Bilateral upper blepharoplasty under local anesthesia with oral sedation.
Medical history
Controlled hypertension. No dry eye, glaucoma or thyroid eye disease. Never smoked.
Medications and allergies
Lisinopril 10 mg daily. Low-dose aspirin, to stop 7 days before surgery. Allergic to penicillin, rash.
Examination
Excess upper lid skin touching lashes on both sides. Brow position normal. Visual fields affected at the top.
Risks and alternatives discussed
Bleeding, asymmetry, dry eye, scarring, rare vision loss. Brow lift and no surgery also discussed.
Pre-operative instructions
No makeup on the day. Arrange a driver. Stop fish oil and vitamin E now.
Consent
Written consent signed. Copy given.
Plan
Surgery in 3 weeks. Pre-op photos taken today.