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Microsoft word - medications to avoid

MEDICATIONS, VITAMINS AND SUPPLEMENTS TO AVOID
Your safety in surgery requires that you disclose all medications, vitamins and supplements that you regularly take. In the days prior to surgery, you will be required to stop taking certain medications, vitamins and supplements, both those you regularly take, and those that may be taken incidentally for pain or other symptoms. Please notify our office of any and all medications you take during the 14 days prior to surgery. If you have taken a medication that may put you at risk, it may require that your surgery be rescheduled, or postponed.
Before you stop taking any prescription drugs, you must receive clearance from the prescribing physician.
Please notify our office immediately if you do not receive clearance to stop taking your prescribed medications.

The following drugs could cause life-threatening problems with surgery. If you are on these you must discuss this

with the doctor. Patients who take these drugs may require laboratory tests and a consultation with their
physician to determine when they may safely undergo a surgical procedure.


Coumadin
Fragmin and other Low Molecular Weight Heparin Drugs

Aspirin and aspirin-containing medications and anti-inflammatory agents must not be taken in the 2 weeks

prior to surgery. Always read the active ingredients on any over the counter or prescription drug packaging.
Attached is a listing of common drugs containing aspirin for your reference.

All Herbal or Dietary Supplements should be stopped 2 weeks prior to surgery. This includes vitamins, and
anti-oxidants supplements, as well as consumption of any form of Green Tea.

There are several categories of additional medications that must not be taken in the 2 weeks prior to surgery.
A
AUTHORIZATION
I have disclosed all of the medications, supplements and herbal remedies I take on a regular or incidental basis to my physician. I understand that I am required to refrain from taking any of the above and below listed medications in the days prior to surgery. Should I take any of the medications, supplements or herbal remedies I am instructed to avoid, it is my obligation to notify my physician immediately. I fully understand that my surgery may have to be rescheduled or postponed in the event that I have not complied with these medication restrictions listed. I also understand that it is my responsibility to obtain clearance from the prescribing physician before I stop taking any of my regularly prescribed medications. Patient Signature or Personal Representative Printed Name of Patient or Personal Representative Relationship Signature of Practice Representative (and Witness) MEDICATIONS, VITAMINS AND SUPPLEMENTS TO AVOID
ASPIRIN AND ASPIRIN CONTAINING MEDICATIONS, INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:

Alka Seltzer

ANTI-INFLAMMATORY MEDICATIONS INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING:

Advil

ADDITIONAL MEDICATIONS TO AVOID, INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:

Source: http://www.bolithomd.com/consent-forms/medications-to-avoid.pdf

Deer run dental

Welcome to our Practice! Please help us by providing the following confidential information. PATIENT INFORMATION Name (last, first, middle):_____________________________________________Preferred________________ Date of Birth_________________ Sex : M_______ F_______ SS#_________________________________ Drivers License #:_____________________ Email address___________________________

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