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Home My WebLink AboutCorrespondence APPLICANT 6/18/2009 ~ I It~; q-rt~~ }./' 111"~ . h. "I " ., , c. ,VRel>1 : I I 5,..6,); I I I ~.4--;h;?l.: I I I f/6..';<-- ; I I I I I I I I I I . _, ' '~ / 5(,iJ~..i.- ::( 0 0 'j ',' . ~. 'p, ~,. .' . t. ~. ?rl~~tf.: /.vI ~, I;ll :t ~./:c f'~A;t:1 ou~ M>vL E~ ~ ~ , I tf_l~ }J ~~ Date Received;- ~jT'lfD-'( .' " Planner-i--MM ( . , (, ~. 'f ,)( ~ ~ .r;;z;44./J<1U'~ I ;.Wd__j.~'p ~~';:"'"'"t", , ~7(5~ 7''1' 77 ,Ai.. l~ H~~ O~...e~?l. 0">2. -1 t{,~ ;?~tJ't ~..-L , "'U./-dr ~:ti~7-(/ 6[, 7A.4t.i_vt... ~1;,:, .: v A. Yk-- u...dJ.._~ ~_I..J.e.o..U--- 15. , Jto.-. <'", v'-L.- A'--v1.. 1..4.A:, ~ ~ ~ So ;''14A-~~eL. n,,-r- ~~, (', . ~ fc.::rJ'--1 ~2 ~ ~ , . /f-r ?z<r c.d'z:L ..:n'k.',..~.f~,t/ vr ~~ .D. /J..o.-/:.Uz."k-<.- _~,_ (~ <Y1. -p.-"...~--t;:,.,,-,-... &;t2""UJ1. ~'7 ern #~I-L?(J; <! 11 ~, ~~ '1-1'1 It e. '5 ~p ..7"-'5..v '. ' ~ (~ u ./ ,/ , ~ /J.......... h..p>V--1 "'......'..H;,k....:z::, -?:I1-~d_~. V r 4, _P.:e7;t:;,..,.. A...u~ <fl:l.._/~~ ~"O CJ ' 4-,-~~_~_~ ~,~_dr_wd:!!z _/~ ~. ~ -a.A.... W.:.4.. ;~ eLM 1Jvr/ ~~ r- '~I- ,\' " , , " ~<" ).... """.1 " ......' "', I~ ~ ~.J' , .. .-'" "; I~ ~ :~~,~ . . ,,-, '---.___'.._:t.~Vi8:)8.l.i E":dSO t~~.;; :'r3~'~,~I~:.t 'I,'> - ~ -.'~ ..... .. '1, " , ...... ,....\ , '. '.-", .< '.-, .', '. , .. \'~ '"'=" " r.' , " ~ ""\:-' , J.~ .,. ~ ..-' ~ \ < ',' .,' \, 'J " " ,', ~.~. ~'-' .- ',\ A :,f; .' ~ "\'. -, \- ~~.' \ ~ " '. " , ,- \ , ~' , '. \ ~. .J2 ~~ ~~ U ;7 ~/~~~ V crn_', ~~' ~'::/,-Lb , l J .-r/~ ,~ 17, " ,~,~~-:;, , ....... " ... .. " . ~ - -' ..l.' .... .~". ":-'.~-' ;t' .... ., " . ~.'" .1 " ..... ,~ .' -." .- " ....... '.: ~. \. " , '':':'" . t~, ~, ~ " , , - .'...' '. , -, (-. -- , - ~t -t.\. , a~ '..i" ..:; ~e. B'"' V A Roseburg Healthcare System Operative Services Pre-Operative Information " Patient Name: 0'R LL IQ/!-L Last four: 13 S- " t'Y) CJnI.:y _ ~ Historv & Phvsical -7 '--'Y ;\Jtf DS DATE: oe,1 Ie::. I TIME: /000 Consent signed 'I i) DA TE~A<-f oC: TIM~: ~~;-v,"1 ""'~ p\..,\5 ''-4-\ Pre treatment: Dr. Bergreen Surgeon: Dr, Skoglund SSU (4th 110or) DATE: b/ IS TIME: J ZOO Snrgcrv: +tA t5(A.yCt-HM 0+: CioJ~~ <... -::'_'-;",v-'_'/ ~ ,..:l~ J ~ Procedure: II-< e. \3'- Anesthesia: Conscious sedation General Spinal Other Surgerv Dav: SSU (4th 110or) DATE:~l.A.....e..;:)4- W ~ TIME: ~: .:b Surgerv Instructions: .. You MUST bring a reliable driver with you to the SSU check in, .. Review medications listed on the back of this paper. . . Nothing to eat or drink to include gum after midnight the night before surgerv. ~C3.,so~~ ....~.~ ~ . Remove all jewelry including piercings and leave at home, . Questions or concerns call 800-549-8387 or 440-1000 ext 44150, To cancel due to illness (fever or cold) or to reschedule call 800-549.8387 or 541-440-1000 ext 45404/44150 - Date ReceiVed:Aa. I~ ~r Planner: MM , LD\)ji~~l 1-- PLEASE DO NOT STOP YOUR BLOOD PRESSURE OR HEART MEDICATIONS OR DIABETIC MEDICATIONS. CHECK WITH YOUR DOCTOFI BEFORE STOPPING 5 DAYS BEFORE PROCEDURE..... CLO! REL (PLA VIX) COUMA IN (WARFARIN) AGGRE X (D11' ndDAlVIOLE) TICLID (' ICLOPIDINE) ALL MEDICATIONS LISTED BELOW STOP 1 0 DAYS BEFORE /...p )1'-1 .s.u f'I~ ~ PROCEDURE. V- THESE MEDICATIONS CONTAIN ASPIRIN OR BLOOD THINNING PROPERTIES (THEY THIN YOUR BLOOD). ADVIL ALKA-SEL TSER ALEVE ASPIRIN CELEBREX DICLOFENAC ETODOLAC IBUPROFEN MOTRIN SALSALATE NAPROXEN SULlNDAC VIOXX PIROXICAM (FELDENE) ARTHRITIS MEDICINE ANTI-INFLAMMATORY MEDICINE IRON ALL HERBAL VITAMINS ALFALFA CHAMOMILE GARLIC PILLS GINGKO GINSENG KAVA LICORICE (PILLS) FISH OIL (OMEGA 3) VITAMIN E MULTIVITAMINS A 1-- L.- ALL- '(.}u-- Ii \-:-~.^S , lY' . ,.. e.r ~S [of f..IU3..s . ++++++IF YOU ARE UNSURE IF A MEDICATION CONTAINS ASPIRIN OR BLOOD THINNING PROPERTIES, ASK YOUR PHARMACIST OR NURSE AT THE V A+++++ 1-800-549-8387 OR 440-1000 EXT 144150 - UROLOGY CLINIC NURSE EXT 144969 - SHpRT STAY UNIT NURSES "