Joint and Spine Camp Form

Digital Signature *

By signing my name, I confirm that I have viewed the Centennial Hills Hospital Medical Center's pre-surgical education video series.

Name of Surgeon *

Best Way to Contact *

Phone

E-mail

Phone

Email

Scheduled Surgery Date

Year

Month

Day

Many of the hospital procedures will help meet our number one priority for your care, which is: *

A. To have fun

B. To make sure the food is good

C. To keep you safe

What should you bring to your pre-surgery appointment? Choose one of the following: *

A. Government ID

B. Insurance information

C. List of medications and dosages

D. Other health information, as needed

E. All of the above

I will be given a cleansing solution at my pre-surgery visit to help prevent surgical site infections. *

A. True

B. False

Foot or leg pumps and compression stockings help to circulate your blood and prevent: *

A. Blood clots

B. Pneumonia

C. Hunger

The breathing tool called incentive spirometer is used to help prevent: *

A. Hunger

B. Fractures

C. Pneumonia

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