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Physician
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Patient
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Diagnosis
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Pre Op Orders
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Informed Consent
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Cataract removal with probable lens impant
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Anesthesia
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Pre-Operative Testing Per Anesthesia Guidelines
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Pre-Op Per Anesthesia
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Old chart and Films if Available
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IV Access, Solutions & Rate
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• • •
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Pre-Operative Meds:
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• • •
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Other
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Other
• • •
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Post-Op Orders
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Physician Signature
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Date/Time
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