Pre-op Screening Form

Patient Rights
Pacific Hills Surgery Center has established this Patient’s Bill of Rights as a policy with the expectation that observance of these rights will contribute to more effective patient care and greater satisfaction for the patient, his/her physician, and the facility organization. It is recognized that a personal relationship between the physician and the patient is essential for the provision of proper medical care. The traditional physician-patient relationship takes on a new dimension when care is rendered within an organized structure. Legal precedent has established that the facility itself also has a responsibility to the patient. It is in recognition of these factors that these rights are affirmed. No catalog of rights can guarantee the patient the kind of treatment he has a right to expect. This facility has many functions to perform, including the prevention and treatment of disease, the education of both health professionals and patients. All these activities must be conducted with an overriding concern for the patient, and above all, the recognition of his/her dignity as a human being. Success in achieving this recognition assures success in the defense of the rights of the patient. AS A PATIENT, YOU HAVE THE RIGHT TO:
  • Considerate, respectful care at all times and under all circumstances with recognition of your personal dignity.
  • Personal and informational privacy and security for self and property.
  • Have a surrogate (parent, legal guardian, person with medical power of attorney) exercise the Patient Rights when you are unable to do so, without coercion, discrimination or retaliation.
  • Confidentiality of records and disclosures and the right to access information contained in your clinical record. Except when required by law, you have the right to approve or refuse the release of records.
  • Information concerning your diagnosis, treatment and prognosis, to the degree known.
  • Participate in decision involving your healthcare and be fully informed of and to consent or refuse to participate in any unusual, experimental or research project without compromising your access to services.
  • Make decision about medical care, including the right to accept or refuse medical or surgical treatment without coercion, discrimination or retaliation.
  • Competent, caring healthcare providers who act as your advocates and treats your pain as effectively as possible.
  • Know the identity and professional status of individuals providing services and be provided with adequate education regarding self-care at home, written in language you can understand.
  • Be free from unnecessary use of physical or chemical restraint and or seclusion as a means of coercion, convenience or retaliation.
  • Know the reasons for transfer either inside or outside the facility.
  • Impartial access to treatment regardless of race, age, color, sex, national origin, religion, handicap, or disability.
  • Receive an itemized bill for all services within a reasonable period of time and be informed of the source of reimbursement and any limitations or constraints placed upon your care.
  • File a grievance with the facility by contacting the Clinical Director, via telephone or in writing, when you feel your rights have been violated.
24022 Calle De La Plata Ste 180 Laguna Hills, CA 92653 (949) 458-3551 Kristi Morse, R.N., Ext 165 Carol Pagard, Ext 170
  • Report any comments concerning the quality of services provided to you during the time spent at the facility and receive fair follow-up on your comments.
  • Know about any business relationships among the facility, healthcare providers, and others that might influence your care or treatment.
  • Know the reason(s) for your transfer either inside or outside the surgery center.
  • File a complaint of suspected violation of health department regulations and/or patient rights. Complaints may be filed at:
Medical Board of California Consumer Complaints (800) 633-2322 (This is posted in the waiting area in larger print) Office of the Medicare Beneficiary Ombudsman AS A PATIENT, YOUR CONDUCT, PARTICIPATION AND YOUR RESPONSIBILITY FOR:
  • Providing, to the best of your knowledge, accurate and complete information about your present health status and past medical history and reporting any unexpected changes to the appropriate physician(s).
  • The care a patient receives is partially dependent on the patients conduct and participation. These responsibilities shall be presented to the patient in the spirit of mutual trust and respect.
  • Following the treatment plan recommended by the primary physician involved in your case including the instructions of nurses and other health professionals, as they carry out the physician’s orders.
  • The patient is responsible for making it known whether he/she clearly comprehends the course of his/her medical treatment and what is expected of him/her.
  • Providing an adult to transport you home after surgery and an adult to be responsible for you at home for the first 24 hours after surgery, if required by your physician.
  • The patient is responsible for keeping appointments and for notifying Pacific Hills Surgery Center or their physician when he/she is unable to do so.
  • The patient is responsible for being considerate of the rights of other patients and facility personnel.
  • Your actions if you refuse treatment, leave the facility against the advice of the physician, and/or do not follow the physician’s instructions relating to your care.
  • Ensuring that the financial obligations of your healthcare are fulfilled as expediently as possible.
  • Providing information about, and/or copies of any living will, power of attorney or other directive that you desire us to know about.

Before You Arrive
Know your Surgery Date and Time of Arrival. Your surgeon’s office will schedule your surgery and will inform you of the date. Please be aware that a member of our clinical staff will call you the day before surgery to give you an arrival time. If you are not contacted by 3pm the day before surgery or have questions, call us at 949-458-3551.

Make arrangements for transportation. You will not be allowed to drive yourself home if you receive anesthesia. Unless directed otherwise, you must have a responsible adult to drive you home and it is advised someone is home with you for the first 24 hours after surgery.

Know your Financial Responsibility. You will be contacted by our Business Office 1-day prior to surgery to review any deductibles, co-payments, co-insurance, and any fees due prior to surgery. It is your responsibility to pay any monies due prior to surgery. Any questions, please call our Business Office at 949-458-3551.

Patient Forms. We encourage you to fill out forms provided in your brochure prior to arriving at facility. It will speed up your registration process. You can also download forms from this page.

On The Day Of Surgery
Items to Bring:
  • Insurance Cards (current cards please)
  • Picture ID
  • List of all medications and their dosages
  • Brochure with completed forms (given out in surgeon’s office)
  • Form of payment (Cash, Check, Charge) if any monies are due
  • Advance Directive (If you have one, please bring a copy)

Pre-operative Instructions
  • DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT, THE DAY BEFORE SURGERY. The only exception is a sip of water with any medications you may take for your heart, blood pressure, or seizure disorder. Failure to comply may result in your surgery being cancelled.
  • Make sure you know your arrival time. Arrive at least 1 hour prior to planned surgical time.
  • Do not wear jewelry, make-up, or bring valuables.
  • You may bathe/shower prior to surgery, but do not put on body lotion on your skin.
  • Wear comfortable, loose-fitting clothing. (Button down shirt and slip-on shoes is best)
  • If you have Asthma, bring your inhaler with you
  • If you are Diabetic, please follow your surgeon’s directions or contact your primary doctor. Our clinical staff can review this with you during the pre-op phone call.
  • Bring your kit with you (eye patients) if instructed by surgeon.
  • If you were sent to your Primary or Specialist for a Medical Clearance, please make sure that office faxed all pre-op labs, EKG and history and physical to our facility. Our fax number is 949-951-9478.
  • Any questions, do not hesitate to call our facility at 949-458-3551.

While In Pre-op
  • You will be taken care of by a Registered Nurse. You will have the opportunity to speak with your Anesthesiologist before surgery as well.
  • We will monitor your vital signs.
  • We will start an IV (for MAC or General Anesthesia).

After Surgery
  • We will provide each patient with specific instructions from your surgeon. You may also have received instructions in the office. You should have a follow-up appointment scheduled with your surgeon’s office. If not, call to arrange one.
  • You will be in the Recovery Area for approximately 20 minutes following surgery if you received Local or MAC anesthesia (light IV sedation). If you are having General Anesthesia, plan to be in recovery for at least 1 hour.
  • If your ride is not waiting at the facility, make sure you have a working cell phone number or home phone number that we can call for pick-up.
  • Patient Satisfaction Survey-We appreciate your feedback! (Icon with link for Patient Satisfaction Survey for patient to complete and send back to us following surgery.)