Welcome to Northbank Surgical Center. The staff thanks you and your physician for choosing us for your
outpatient surgical procedure. Northbank Surgical Center is a freestanding ambulatory surgical
facility designed with you in mind. We are proud to offer quality care, specialized equipment, and advanced
technology in a safe, family-friendly environment.
The staff of Northbank Surgical Center welcomes this opportunity to be of service to you and your family. We
are dedicated to making your stay as pleasant as possible and welcome any comments
or suggestions you may have. If you have a question or concern, please contact us at 503-364-3704.
Please visit our website (www.northbanksurgerycenter.com) for further information
regarding registration, directions, payment information, and more.
If at any time you have questions, please feel free to call us at 503-364-3704.
DIRECTIONS
Heading South on I-5
Take Exit 253 to Hwy22 / 99E /
Mission Street SE and turn right.
Continue on Mission Street to 12th
Street SE.
Turn left on 12th Street
SE.
Continue on 12th Street SE approximately 1.1 miles to 2525 12th Street SE and turn
right at the light into the parking lot.
Heading North on I-5
Take Exit 253 to Hwy22 / 99E /
Mission Street SE and turn left.
Continue on Mission Street to 12th
Street SE.
Turn left on 12th Street
SE.
Continue on 12th Street SE approximately 1.1 miles to 2525 12th Street SE and turn
right at the light into the parking lot.
From West Salem - Wallace Road
Merge onto OR-22 / Center St. Bridge via the ramp to Salem.
Using the right lane, merge onto OR-22
/ OR-99E BUS S / Front Street via the ramp to
Albany.
Remain on OR-22 / OR-99E BUS S/ Front Street (Front St.
becomes Trade St., Trade becomes
Bellevue St.) to 12th
Street.
Turn right on 12th Street
SE.
Continue on 12th Street SE approximately 1.1 miles to 2525 12th Street SE and turn
right at the light into the parking lot.
Page 1
Patient Registration Guide
Physician:
Procedure Date:
Northbank Surgical Center asks that you complete online registration with One
Medical Passport. The website will guide you to enter your Medical
history so that we may provide you with excellent care and minimize long phone interviews and paperwork.
Begin Registration on the One Medical Passport Website
Start on our homepage:www.northbanksurgerycenter.com
and click "Pre-Registration" to
go to One Medical Passport (shown below).
Create Your One Medical Passport Account
First time users of onemedicalpassport.com should click the green Register button
and create an account. Answer the questions on each page, then click
save and continue. Once complete, you will be prompted to click Finish to
securely submit your information to us.
First Time Website Users Click Register
Username you chose:
Returning Users (for changes or reuse)
Enter the username and password you chose.
You can then access or update your account.
Additional Help to Complete Registration
Each page has a Help link you may click for assistance. If you are unable to
complete your history online, a pre-admission nurse will contact you by
phone close to the date of your procedure to complete your history with you.
Page 2
Board-Certified Ophthalmologist
Phone 503.581.5287 Fax 503.386.1377
CATARACT PRE-OP & POST-OP INSTRUCTIONS
Prior to Surgery
Please bring these items to surgery
Fill all medication eye drop prescriptions at your pharmacy.
Start all drops as directed 1 day before surgery.
Arrange for a driver to bring you to and from your surgery appointment.
We ask that only one person accompany you to the surgery center.
And that you arrive no earlier than your scheduled time of:
Day
Date
Time
You will be at the surgery center for approximately 1 hour and 30 minutes,
from check-in to discharge.
The Night Before
Make sure to shower,
wash hair and face.
Eat and drink as usual.
Take all medications unless
otherwise instructed by
your surgeon.
Independent Physician at Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 3
Page 3
Day of Surgery
Be careful of your eye(s).
Do not rub, bump, touch, or
squeeze your eyelid(s).
Eat a light meal two hours
prior to your procedure. Take
all medications unless other-
wise instructed.
Absolutely no caffeine,
alcohol or marijuana the
day of your surgery.
No earrings or face jewelry.
Remove and leave all jewelry
at home. Medical alert tags
and wedding rings are OK.
Wear loose clothes and short
sleeves. Slacks are suggested for
ladies. Tennis shoes or similar
types of rubber-soled shoes
are requested for your safety.
Do not wear make-up, face
or body lotions, perfume or
cologne. No scented or alcohol-
based products on your hair or
skin, including:
If you are an insulin-taking diabetic, please do not eat or take your insulin. No food or drink 6
hours prior to surgery.
It is ok to take your oral diabetic medication.
No hairspray, mousse, gel, detangler, leave-in- conditioner, etc. No deodorant or antiperspirant, shave
gel, after shave, mouthwash, mints, etc. These products are prohibited as they can damage the
ultra-sensitive laser optics.
You will be sent home from surgery wearing a plastic shield to protect your eye. Your surgeon
will
remove it at your 1 day post-op appointment. Do continue using your prescribed eye drops as directed
when
you get home in your surgery eye only.
Please bring to surgery: your glass case if you wear glasses. Also bring a current medical insurance
cards
and a photo ID (if this does not show your current address, you must also bring a utility bill or other
correspondence which shows your current address.) Note: the photo ID is necessary because we are now required to comply with federal
identity-theft
prevention laws.
We recommend that you nap as long as possible to jump start your healing process.
Independent Physician at Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 4
Page 4
Patient Name
Surgery Eye:
Post-Op Appointment Date / Time
Cataract Post-Op Instructions
Use your eye drops on the schedule provided by your surgeon.
No lifting over 10-15 pounds for 1 week.
Do not rub your eye, or get anything in your eye, which can increase the chance of infection.
Avoid running the shower in your eye for 1 week. Bathe and shower with your eyes closed.
No hot tubs, swimming pools, bodies of water, saunas or tanning beds for 1 week.
No eye make-up or under eye cream for 1 week.
Do wear glasses or sunglasses during the day for comfort.
Wear your protective eye cover-ing (eye shield) as prescribed and avoid sleeping on the side that had
been
operated on.
If you are currently using drops for glaucoma continue all drops as directed.
Bring all eye drop medications to post-op appointments.
Call the office at (503) 581-5287 if you experience any pain, red-ness, or change in vision for
the
worse in the operative eye, or for any other concerns relating to your eye.
Eye Drop Medication
Instill 1 drop in the surgery eye for the medications as indicated below :
Instill drop 4 times daily in surgery eye only.
Instill drop 2 times daily in surgery eye only.
Instill drop 1 times daily in surgery eye only.
Instill drop 2 times daily in surgery eye only.
Instill drop 4 times daily in surgery eye only.
Instill drop 1 times daily in surgery eye only.
Independent Physician at Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 5
Page 5
Northbank Surgical Center
Physician's Order Sheet
Patient Name:
PRE-OPERATIVE ORDERS
1.
Diagnosis:
Mild/Moderate Glaucoma-
2.
Procedure:
3.
Admit to Northbank Surgical Center
4.
Check Medication Reconciliation sheet for allergies.
5.
Routine admitting vital signs
6.
Anesthesiologist to evaluate patient if MAC
7.
Start saline lock. May use lidocaine 2%, 0.1 to 0.2 ml for local anesthesia for insertion of IV needle.
8.
Place H&P in chart.
9.
PRE-OP MEDICATIONS:
Proparacaine 0.5% ophthalmic solution, 1-3 drops in operative eye PRN.
Give 1 drop ofCompounded DILATING
ophthalmic
solution [contents below] in operative eye; repeat in 10 minutes PRN:
-Tropicamide 1%
-Phenylephrine 2.5%
-Cyclopentolate 1%
-Ketorolac 0.4%
Give 0.5mg Versed IVP on call to OR.
10.
Check blood glucose level preoperatively on all insulin dependent patients.
11.
If lists, and/or patient reports EVER using an alpha adrenergic medication,
give Atropine Sulfate 1% ophthalmic solution, 1 drop in operative eye; repeat in 5 minutes.
12.
Other
INTRA-OPERATIVE ORDERS
1.
Routine per preference card
2.
Other
POST-OP APPOINTMENT:
Date:
Time:
Signature
MD
Date:
Time:
PHYSICIAN ORDER SHEET Rev. 06/17
(PATIENT LABEL)
Page 6
INTRAOCULAR LENS REQUEST
To: Northwest Medical
From:
Patient:
DOB:
Age:
Sx Date:
Primary
Diopter
Back Up
Diopter
OTHER
Comments
Verified ( Surgeon )
Date
Submitted ( Tech )
Date
Time
MCEC OFFICE USE ONLY
Page 7
Board-Certified Ophthalmologist
Phone 503.581.5287 Fax 503.386.1377
CATARACT SURGERY WITH IOL (INTRAOCULAR LENS)
Patient Name:
DOB:
A cataract develops when the lens in your eye becomes cloudy. The lens is part of your eye that
helps focus images. Cataracts can cause problems such as blurry or dulled vision, sensitivity to light
and
glare, and seeing shadows or ghost–like images.
Cataracts always get worse. Surgery is the only way to remove it. It is your choice when to have
cataract surgery. Most people wait until their vision problems interfere with daily life. You can also
decide not to have your cataract removed.
During cataract surgery, your eye surgeon will remove the cloudy lens. He will replace it with
an IOL—intraocular
lens, a clear plastic artificial lens. The most common is a monofocal (one focus) IOL. This
helps
improve vision at mostly just one distance, either near or far. You will probably need glasses to see
clearly at other distances.
Cataract surgery only corrects vision problems caused by cataracts. This surgery cannot correct
vision problems caused by glaucoma, diabetes, age-related macular degeneration, or other eye illnesses
or
injuries.
Many patients with cataracts also have astigmatism or presbyopia (eye problems that make it hard
to
see).
Astigmatism causes blurry vision. Normally, the clear window of the eye, the cornea, is round
like a
ball. If an eye has astigmatism, the cornea is more football–shaped. This blurs the focus.
Presbyopia makes it hard for the eye to focus at near. Most people get this as they age. People
at
any age who have cataract surgery with a monofocal IOL focused for distance vision will have some
presbyopia. People with presbyopia might hold a book or menu at arm’s length to try to see it more
clearly.
Glasses help astigmatism and presbyopia. If you want to wear glasses less often, the eye surgeon can
put in
a special IOL or do an extra procedure during cataract surgery to treat these eye problems.
You have to pay extra for special IOLs or extra surgical procedures. Medicare and private
insurance
do not pay for these. Your eye surgeon will let you know if you have astigmatism or presbyopia. Your
eye
surgeon will give you more information if you are interested in these treatments. You will be asked to
sign
another consent for them.
Cataract surgery is usually safe and successful. As with all surgery, there are risks (problems that can
happen) with cataract surgery. While the eye surgeon cannot tell you about every risk, here are some of the
common or serious risks:
Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 8
Page 8
Board-Certified Ophthalmologist
Phone 503.581.5287 Fax 503.386.1377
CATARACT SURGERY WITH IOL (INTRAOCULAR LENS)
•
•
Risks from cataract surgery include vision loss, blindness, or not getting the result you
want.
You could also have bleeding, infection, a droopy eyelid, or glaucoma (high eye pressure). You
could
get a detached retina. This is when the retina, at the back of the eye, pulls away from where it is
attached. You may need surgery to fix the detached retina. Your eye may be injured by surgery or
anesthesia. You may need another surgery later to take out pieces of the cataract that were not
removed
during the cataract surgery.
Risks from an IOL. The IOL may be too weak or too strong. The eye surgeon might not be able
to
insert the IOL of your choice. The eye surgeon may need to replace or reposition your IOL months or
years after surgery.
•
•
•
•
Problems during surgery that need immediate treatment. Your surgeon may need to do more
surgery
right away or change your surgery to treat this new problem.
Anesthesia can cause heart and breathing problems. Very rarely, it can cause death.
Anesthesia
can also injure your eye and cause vision loss or double vision.
Other risks. There is no guarantee that cataract surgery will improve your vision. It is
possible that cataract surgery or anesthesia may make your vision worse, cause blindness, or even
the
loss of an eye. These problems can appear weeks, months, or even years after surgery.
You may need to wear glasses after cataract surgery.
CONSENT. By signing below, you consent (agree) that:
• You read this informed consent form, or someone read it to
you.
• You understand the information in this informed consent form.
• The eye surgeon or staff offered you a copy of this informed
consent form.
• The eye surgeon or staff answered your questions about
cataract
surgery.
• Your eye surgeon or staff have discussed presbyopia following
cataract surgery and ways to treat it.
• If you have astigmatism, the eye surgeon or staff discussed
ways
to treat it.
• You understand that you may need to wear glasses after
surgery.
(intraocular lens) in my
eye.
Patient Signature
Date
Time
Witness Signature
Date
Time
Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 9
Page 9
MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
(503) 581-5287
Co-Management Release Form
Patient Name:
I will be given an information sheet explaining the post-operative surgery
instructions,
appointments needed, and the care of my eye following surgery. This has been explained by my
surgeon. l
understand that l am to return to either my surgeon or regular ophthalmologist / optometrist
following
surgery for an appropriate period of time in order to ensure that my recovery is progressing
normally.
Please choose one option below:
I have informed my surgeon that it will be more convenient for me to have my
post-operative care
preformed by my ophthalmologist/ optometrist when it is medically appropriate. l have discussed
this
program with my ophthalmologist / optometrist and he/she is willing to perform these services
and
consult
with my surgeon as needed for my care. My ophthalmologist / optometrist also has agreed to
provide
my
surgeon with a copy of my record after each post-operative visit.
My surgeon has assured me that l can contact his office at any time with any
questions
or for
any problems, and if I choose to return to him at any time during the post-operative period, l
may
do so.
l have informed my surgeon that it will be more convenient for me to receive my
post-operative
care from him. It is my choice not to return to my ophthalmologist / optometrist for my
post-operative
care.