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SURGERY WITH DR UEBELHOER
PRE-OP COUNSELING & CONSENT
Today's Date
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Patient Name
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First Name
Last Name
Date of Birth
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Email
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By initialing each statement, I confirm that I read and understand the information below:
If I prefer non-surgical options, I will not sign this form and do not need to continue filling it out. You have the option to schedule an appointment with your general dermatologist to review options or get a second opinion from another provider.
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If I prefer treatment alternatives or a second opinion, I will schedule a non-surgical appointment with my general dermatologist or Dr. Uebelhoer.
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I understand the time I am given is my Check-in time, not my actual appointment time and that I may wait up to 1 hour before actually being seen. During this time, the surgeon and his team will be prepping for my case.
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I understand that the surgery process can take a long time (up to 4 hours) due to the time it takes to prepare for surgery, the procedure time and bandaging with post opinstructions.
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If I prefer treatment alternatives or a second opinion, I will schedule a non-surgical appointment with my general dermatologist or Dr. Uebelhoer.
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I understand that Dr. Uebelhoer may need to refer me to another specialist if he finds the site to be better treated under general anesthesia or by a different specialty.
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Dr. Uebelhoer does not “negotiate“ his decision to cancel or perform surgery, his technique, or fundamental preoperative, intraoperative, or postoperative principles and procedures. If I want the procedure done a specific way (such as “the way my other doctor did it...”) or I cannot commit to following instructions specific for my case, or I simply cannot accept the potential wait times, surgical follow-up, suture removal schedules, etc., I will let San Diego Family Dermatology know BEFORE I schedule mysurgery.
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SCHEDULING MY SURGERY DATE
I will not schedule any travel for at least 10 days following surgery.
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I will notify San Diego Family Dermatology if I have travel scheduled within 28 days of my surgery as sutures can be in for 1-6 weeks.
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I will prepare to be in the clinic for 4+ hours.
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I will only have one family member/caregiver with me on my surgery day. They are welcome to wait or leave and come back, however due to waiting room size restrictions we have to limit the number of people that come with you.
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I will arrange a driver as medications may be given during the procedure that may alter my ability to drive.
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My driver's name is:
First Name
Last Name
My driver's phone number is:
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Area Code
Phone Number
I will arrange to have someone watch over me for the first 24 hours as medications, bandages or pain may alter my ability to fully care for myself.
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My caregiver's name is:
First Name
Last Name
My caregiver's phone number is:
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Area Code
Phone Number
I will contact the office 3 business days prior to my surgery for any cancellations or rescheduling. Otherwise, I may be charged a $50.00 cancellation fee. After canceling or rescheduling 2+ times, we may need to schedule a consultation with Dr. Uebelhoer prior to rescheduling your procedure.
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I will prepare supplies that I will need at home before surgery: ● If the surgical site is on the lip, jaw or cheek, have soft foods available. ● If the surgical site is on the foot or lower leg we highly recommend purchasing compression socks (20-30 mmHg), a postoperative boot (please try it on beforecoming to the procedure) and a shower cover for your leg. (Examples on Amazon are: Aircast AirSelect Elite Walker Brace / Walking Boot and TKWC INC Waterproof Leg Cast Cover for Shower - #5738) ● Other supplies such as gauze, tape, non-stick pads, different size bandages, Aquaphor or Vaseline and gentle wound cleaner are needed for ALL SURGERIES.
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PLANNING FOR MY SURGERY DAY
I will plan for a good night’s sleep the night before surgery
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I will eat a full breakfast (which includes protein, carbohydrates and water prior to surgery)
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I will take all of my regular medications unless directed specifically by my doctor.
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I will bring an updated list of my medications to surgery.
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Do you usually take antibiotics prior to a procedure?
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No
Yes
I will not wear makeup, hairspray, fragrances or lotions.
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I will wear comfortable clothes, including a button-up shirt that is easy to take off without going over my face or the affected surgical site.
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I will bring reading material or something to help the time go by. Earphones are encouraged; however, they may not be compatible during certain times of my surgery. I am aware the office does have wifi to use during my wait time.
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I am to go straight home from surgery, with the possible exception of going to the pharmacy.
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I understand it is not necessary to cancel my appointment for cold like symptoms or even covid unless I feel too ill to come in.
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SURGERY DAY
Dr. Uebelhoer will determine if relaxing medications such as Valium or Ativan will be administered in the clinic prior to surgery. **There are several reasons for medications including but not limited to: reduction of pain and bleeding, decrease involuntary muscle contraction to improve safety, and to help me relax. If I plan to refuse these recommended medications I will let San DiegoFamily Dermatology know BEFORE scheduling my surgery date.**
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Some wounds are better treated without stitches at all. This often means I will have more frequent in-office wound care.
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Decisions about stitching the wound will occur at the time of surgery by Dr. Uebelhoer. If I have a preference on how I want my wound repaired, I will let San Diego Family Dermatology know BEFORE scheduling my surgery date.
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AFTER SURGERY
I will be prepared to remain in bed for 72 hours after surgery. This is required for all surgery sites regardless of the diagnosis.
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I will leave only to go to the bathroom or to the kitchen to prepare my meal.
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I will avoid swimming or sitting in a hot tub until my sutures are completely removed.
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I will avoid any activity or exercise that requires me to hold my breath until my sutures have been completely removed.
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I will avoid any strenuous activity or exercise that applies pressure or strain on the wound until my doctor authorizes.
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If I do more activity, I risk development of a wound infection and a poor scar result.
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San Diego Family Dermatology follows standard medical coding and billing procedures. When a repair is performed, certain follow-up visits are included for a specified period of time. When a repair is not performed and the wound is open, more frequent follow-up visits are typically needed. These are separately billed office visits.
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MY SIGNATURE BELOW INDICATES THE FOLLOWING:
I HAVE BEEN GIVEN ADEQUATE TIME TO HAVE ALL OF MY QUESTIONS
ANSWERED.
I HAVE READ AND AGREE TO ALL OF THE ABOVE.
MEDICAL HISTORY IS ACCURATE.
I AM AGREEING TO SURGERY.
PATIENT / GUARDIAN SIGNATURE
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