Salem Laser and Surgery Center
1330 Commercial Street SE
Salem, Oregon 97302
503-763-1973

INSTRUCTIONS FOR SURGERY

The Night Before:
The Day of Surgery:
DAY
DATE
TIME
Becuase waiting room space is very limited, we ask that only one person accompany you and that you arrive no earlier than the time indicated above. Thanks!

  1.  You will not be allowed to drive yourself after you have surgery. Be sure you have someone to drive you home. If you plan to       take a taxi home, you must have responsible adult (other than the driver) accompany you.
  2.  Provide a responsible adult to transport him/her home from the facility and remain with him/her for twenty-four (24) hours, if       required by his/her provider.
  3.  Please bring: 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).

    4.       Note: the photo ID is necessary becuase we are now required to comply with federal indentity-theft prevention laws. Also       bring your glass case if you wear glasses.
Salem Laser and Surgery Center
Physician's Order Sheet

Patient Name:

PRE-OPERATIVE ORDERS
Allergies/Reactions:  

Diagnosis:
  1.   Admit to Salem Laser and Surgery Center
  2.   Routine admitting vital signs
  3.   Nurse Anethetist to evaluate patient if MAC
  4.   Saline lock started
  5.   H & P on chart
  6.   PRE-OP MEDICATIONS
a.

b.

c.
Xanax PO per standing order on admission if local

Proparacaine 0.5%   1-3 gtts prn

Neosynephrine 2.5%












1 drop surgery eye every 5 minutes x3 doses.

7.
Check serum glucose level if on medication for diabetes
8.
Other:

INTRA-OPERATIVE ORDERS
  1.   Routine per preference card
  2.   Other:
POST-OP APPOINTMENT:
DATE:  
TIME:  
Signature:  
MD
Date:  
Time:  

PHYSICIAN ORDER SHEET - GENERAL OPHTH       5/07
(PATIENT LABEL)
Patient:
Date of Birth:
Sx Date:
Co-Manage
Yes         No

Drops

OD

Date

OS

Date
EOM
PUPILS
MR
BAT
NV
PRESSURE

SLE
DILATE
EXAM AT PRE-OP
REFRACT FIRST EYE:
 

BP   P   R
PHYSICAL EXAMINATION
Mental Status:
Other
Heart:
Other
Lungs:
Other
Other:

Plan:      Schedule for surgery
Additional Info.
Change to orders
*SIGN CONSENT
IN EMA*
Pterygium
SALEM LASER AND SURGERY CENTER
1330 Commercial St. SE
Salem, OR 97302
503-763-1973

FEE ESTIMATE

PATIENT NAME:

PLANNED PROCEDURE:

PROCEDURE DATE:

This information tool is to be considered an approximation of facility fees for the procedure identified above and does not cover fees for procedures not scheduled on this date.

SURGEON FEES
Billed seperately by your physician.

ANESTHESIA FEES
Billed seperately by your anesthesia practitioner; questions may be directed to: Anesthesia Associates Northwest, LLC
1-877-222-4217

SURGERY CENTER FEES
The facility billing office will contact you prior to surgery to let you know what your estimated patient portion will be. Billing questions may be directed to the CBO at 1-855-887-4997.

Co-payments are due at the time of your procedure. Co-payments accepted by check, credit card, or exact amount of cash only.

INSURANCE BILLING & STATEMENTS
We participate with many plans and will bill your insurance carrier accordingly. We also accept Medicare assignment.

Depending on your insurance plan and their payment guidelines, you will receive a statment after your surgery. Check your statement for the "Amount Due" box. That is the balance due by you. Call 1-855-887-4997, if you have questions about your surgery billing.

ASK US
Please do not hesitate to call us with any questions or comments you may have. We will assist you as best we can.


8/17     FEE ESTIMATE, CATARACT
Salem Laser & Surgery Center, LLC
Patient Last, First Name
Surgery Date
Eye
Pterygium without Graft
Pterygium with Amniotic Graft
Pterygium with Conjunctival Auto Graft
Mitomycin
5FU
Tisseel Glue
Retrobulbar Block
Tri-Moxi
Notes
Patient Label