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MEDICATIONS, VITAMINS AND SUPPLEMENTS TO AVOID


Your safety in surgery requires that you disclose al medications, vitamins and supplements that you regularly take. In the
(
) days prior to surgery, you wil be required to stop taking certain medications, vitamins and supplements, both those you regularly take, and those that may be taken incidental y for pain or other symptoms. ) M.D. of any and al medications you take during the ( prior to surgery. If you have taken a medication that may put you at risk, it may require that your surgery be rescheduled, or
postponed. This is for your safety.
Before you stop taking any prescription drugs, you must receive clearance from the prescribing physician. Please notify
our office immediately if you do not receive clearance to stop taking your prescribed medications.

The following drugs could cause life-threatening problems with surgery. If you are on these you must discuss this with
the doctor. Patients who take these drugs may require laboratory tests and a consultation with their physician to
determine when they may safely undergo a surgical procedure.

Coumadin
Fragmin and other Low Molecular Weight Heparin Drugs
Aspirin and aspirin-containing medications and anti-inflammatory agents must not be taken in the 2 weeks prior to
surgery. Always read the active ingredients on any over the counter or prescription drug packaging. Attached is a listing of
common drugs containing aspirin for your reference.
All Herbal or Dietary Supplements should be stopped 2 weeks prior to surgery. This includes vitamins, and anti-oxidants
supplements, as wel as consumption of any form of Green Tea.

There are several categories of additional medications that must not be taken in the 2 weeks prior to surgery. A listing of
these drugs is attached.
Authorization
I have disclosed al of the medications, supplements and herbal remedies I take on a regular or incidental basis to
(
I understand that I am required to refrain from taking any of the above and below listed medications in the ( prior to surgery. Should I take any of the medications, supplements or herbal remedies I am instructed to avoid, it is my obligation to notify ( ), M.D. I fully understand that my surgery may have to be rescheduled or postponed in the event that I have not complied with these medication restrictions listed. I also understand that it is my responsibility to obtain clearance from the prescribing physician before I stop taking any of my regularly prescribed medications. Patient Signature or Personal Representative Printed Name of Patient or Personal Representative Relationship of Personal Representative to the Patient Signature of Practice Representative and Witness

Aspirin and aspirin containing medications, include, but are not limited to the following:

Anti-inflammatory medications include but are not limited to the following:

Advil

Additional medications to avoid, include, but are not limited to the following:

Source: http://www.drbortnick.com/wp-content/uploads/2012/12/Medication-avoid-JOL.pdf