Before your scheduled surgical appointment, we ask that you submit your online pre-surgical questionnaire. The information you submit here will be sent to your nurse in preparation for your appointment.
Type of surgery being performedFoot/Ankle----- Plantar Fasciitis Surgery----- Bunionectomy----- Hammertoe Correction----- Achilles Tendon Repair----- Tarsal Tunnel Release----- Ankle Arthroscopy----- Ankle Fracture Repair----- Foot Fracture RepairSpine----- Low Back Surgery----- Neck Surgery----- Spinal Cord Stimulator PlacementKnee----- Knee Arthroscopy----- Patella Surgery----- ACL Repair----- Total Knee ReplacementShoulder----- Shoulder Arthroscopy----- Total Shoulder ReplacementHand/Arm----- Carpal Tunnel Release----- Trigger Finger Surgery----- Wrist Fracture Repair----- Wrist Arthroscopy----- Elbow Surgery----- Thumb Surgery----- Biceps SurgeryHip----- Total Hip ReplacementOther (type in below)
Please remember to bring your insurance information, a picture ID, and a written list of the medicines you are currently taking (please do not bring the actual containers); and we encourage you to wear comfortable clothing and NO jewelry. ALL jewelry worn to the facility must be removed prior to your surgery or your procedure will not be performed. Contact lenses, eye glasses and dentures must be removed prior to surgery. Hearing aids can be worn during most procedures.
It is VERY IMPORTANT not to have anything to eat after midnight the evening prior to your surgery. You may have clear liquids such as water, Gatorade, juices without pulp (apple, cranberry), and/or coffee without milk or cream up to one hour prior to your arrival time at the surgery center the morning of your surgery.
If you are pregnant or think that you may be pregnant, your surgery will need to be rescheduled to a hospital setting. If you have an internal defibrillator or pacemaker in your chest, please bring the information/ID card you were given when the device was implanted.
Insurance coverage (primary)None SelectedAetnaBlue Choice Health Plan (ZCC & ZCL only)Blue Choice HIX (ZCX, ZCJ, ZCM)Blue Cross Blue ShieldBlue Cross Blue Shield HIX (ZCU, ZCQ)Blue Cross Blue Shield State Health PlanBlue Cross FEPCignaChampvaCoventryFirst ChoiceFirst HealthHumanaMedCostMedicareMedicare Advantage PlansMultiPlanPHCSPlanned AdministratorsSC Medicaid and Tricare (Not Prime)SupermedUnited Healthcare (we negotiate all UHC)
Insurance coverage (secondary)None SelectedAetnaBlue Choice Health Plan (ZCC & ZCL only)Blue Choice HIX (ZCX, ZCJ, ZCM)Blue Cross Blue ShieldBlue Cross Blue Shield HIX (ZCU, ZCQ)Blue Cross Blue Shield State Health PlanBlue Cross FEPCignaChampvaCoventryFirst ChoiceFirst HealthHumanaMedCostMedicareMedicare Advantage PlansMultiPlanPHCSPlanned AdministratorsSC Medicaid and Tricare (Not Prime)SupermedUnited Healthcare (we negotiate all UHC)
If you use any medications on a daily basis for heart problems, high blood pressure, high cholesterol, seizures, asthma, or acid reflux and you normally take them in the morning, you may take these medicines the morning of your surgery. If you are diabetic and use medication for your diabetes, please DO NOT take your diabetic medication(s) the morning of your surgery.
Medications You Take Regularly (if any)
Drugs (legal or illegal) Taken Regularly (if any)
If you take any blood thinning medications such as Coumadin, Warfarin, Xarelto, Effient, Brilinta, Eloquis, Plavix, Pradaxa, aspirin, or any anti-inflammatory medicines such as ibuprofen, naproxen or Mobic it is VERY important that you ask your physician whether or not these medications need to be stopped prior to your surgery date. If you use inhalers or a CPAP machine to help you breathe at night, please bring these items with you to the surgery center.
Are you on any blood thinner (Coumadin, Warfarin, Xarelto, Effient, Brilinta, Eloquis, ASA, Plavis, Aspirin, Fish Oil, etc)?NoYes - CoumadinYes - WarfarinYes - XareltoYes - EffientYes - BrilintaYes - EloquisYes - AspirinYes - ASAYes - PlavixYes - Fish OilYes - Other
If Yes, were you told by your doctor to stop taking them?NoYes
Are you allergic to any medications?
Are you allergic to latex or any metals?
You MUST have someone available to drive you home after your surgery or your procedure WILL NOT be performed. You MAY NOT go home in a taxi. There are no exceptions to these rules.
Thank you for using our pre-surgery check-in. The nursing staff at Carolina Bone & Joint Surgery Center can be reached by dialing 843-903-6327 and are happy to discuss any questions or concerns you may have about your appointment at our facility. We look forward to taking great care of you!
Click the box next to "I'm not a robot" then click the SUBMIT button below.