Pediatric Preop Instructions

Busy parents of pediatric patients may call the number below to listen to the pre-recorded instructions regarding your child's anesthesia, IN LIEU OF an actual preop call

We will continue to reach you UNLESS you listen to the entire recording and submit this form with the correct key phrase provided at the end of the recording

469-916-8843 extension 11

Your Child's Name*

First NameLast Name

I am the legal guardian of the child named above*

YesNo

The preoperative instructions must be done by the parent or the legal guardian of the pediatric patient

Please have the legal guardian listen to the preoperative instructions

I will be accompanying my child for at least 12 hours before and 24 hours after anesthesia*

YesNo

I agree to relay this information to the individual who will accompany my child for 12 hours before and after anesthesia*

YesNo

The preoperative instructions must be relayed to the individual who will accompany the patient for at least 12 hours before and 24 hours after the anesthesia

Key Phrase (provided to you at the end of the recording)*

Do you have any further questions?*

YesNo

Phone number where you can be reached*

Please enter a valid phone number.

Briefly describe your question:*

Please note

We understand that parents have busy schedules and have tried our BEST to make the preop instructions process as easy as possible. If you refuse to completely listen to the pre instructions, or are rude or disrespectful to our staff for attempting to provide you with the preop instructions, you may be dismissed from our service.

Signature*

I attest that I have listened to and understood the entire recording, and understand that a refusal to fully listen to our preoperative guidelines may result in a dismissal from our service.