Patient's Name *

First Name

Last Name

Surgery Date

MM

DD

YYYY

When to send your prescriptions to your pharmacy *

Please indicate when you would like for us to send your prescriptions to your pharmacy.

Please send my prescriptions one to two days before my surgery

Please send my prescriptions after my surgery when I am discharged from the hospital

Your Phone *

Please provide us a phone number in case we need to call you about your prescriptions

(###)

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Pain Medicine

Taking pain medicine after surgery is optional, and all patients should try to wean themselves off pain medicines as soon as possible. Our patients under 80 years old usually take Percocet 5's. Our patients over 80 years old usually take Norco 5's, but there is a lot of variation in pain medicine requirements.

I trust your office to send in the pain medicine prescription that is best for me.

Percocet (oxycodone), 5/325, take 1-2 every 6 hrs as needed, #30

Norco (hydrocodone), 5/325, take 1-2 every 6 hrs as needed, #30

Tramadol, 50 mg, take 1-2 every 6 hours as needed, #30

I don't need a pain medication prescription (i.e. I get pain meds elsewhere)

I need a different pain medication prescription - (please write a note in free text field below.)

Blood Thinner

Taking blood thinners after surgery is required. Most patients without a history of blood clots take aspirin. Most patients with a personal or family history of blood clots (DVT/PE) should take Xarelto or Eliquis.

Aspirin, 81 mg, take 1 twice a day, #60 (4 weeks)

Xarelto, 5 mg, take 1 once a day (4 weeks)

Eliquis, 2.5 mg, take 1 once a day (4 weeks)

I am already on a blood thinner

I need a different blood thinner prescription

Nausea Medication

Taking nausea medication after surgery is optional.

Zofran, 4 mg, 1 every 4 hours as needed, #10

Phenergan, 25 mg 1 every 6 hours as needed, #10

I don't need nausea medicine

NSAID

Taking a non-steroidal anti-inflammatory medication (NSAID) after surgery is optional. Many patients do not tolerate NSAIDs because of heart, kidney, stomach or blood pressure issues. If you tolerate NSAIDs, then taking an NSAID can help relieve post operative pain and limit narcotic usage.

Celebrex, 200 mg, take 1 twice a day, #60

Mobic, 15 mg, take 1 twice a day, #60

Naprosyn, 220 mg, take 1 twice a day

Ibuprofen, 800 mg, take 1 three times a day, #90

I can't take NSAIDs

I already have NSAIDs or get them myself

Steroid

Taking an oral steroid after surgery is optional, but most diabetics should avoid any steroids as they can raise your blood sugars.

Prednisone, 5mg, take 1 every day, #7

I don't want to take any steroids

Antibiotic

Taking an oral antibiotic after surgery is optional. If you are sensitive to antibiotics, then I would recommend against taking an antibiotic.

Keflex, 500 mg, take 1 every 8 hrs, #21

Doxycycline, 200mg, take 1 every 12 hrs, #14

I do not tolerate antibiotics

I prefer a different antibiotic

Flomax

Some patients with urinary retention (especially older men with prostate issues) struggle to urinate after surgery. The spinal anesthetic can temporarily increase urinary retention. If you often wake up in the middle of the night to urinate, we recommend taking Flomax for 3 days before and 3 days after surgery.

Flomax 0.4 mg, take 1 every day, #7

I don't need a prescription for urinary retention

I already have a prescription for Flomax

Tranexamic Acid

Tranexamic acid is an oral medicine that helps prevent unwanted post-operative bleeding by slowing down the breakdown of blood clots. It has been safely given during surgery for the past 10–15 years, but recent studies show additional benefit from a short, continued oral dose after surgery.

Yes, I would like a prescription for tranexamic acid. (650 mg tabs, 3 tabs each day for 3 days)

No, I do not want a prescription for tranexamic acid