PROVIDER: Karan Mehta
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Patient Information
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PREFERRED SURGERY DATE:
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PREFERRED START TIME OF SURGERY
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SURGERY DURATION
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SURGICAL FACILITIES:
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PROCEDURE IN DETAIL:
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SURGICAL FIRST ASSISTANT (RNFA OR PA)
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Text Field
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SUPPLIES
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IMPLANTS/SIZERS
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KELLER FUNNEL
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GARMENTS/BINDER
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OTHER
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EXPAREL
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COSMETASSURE
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ANESTHESIA:
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PATHOLOGY FEE:
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PREOPERATIVE LABS :
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BETA HCG
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EKG
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CHEST X-RAY
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PRIMARY CARE CLEARANCE
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OTHER SPECIALIST
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OVERNIGHT STAY
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PREOPERATIVE DATE
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POSTOPERATIVE DATE
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PRESCRIPTIONS (REVIEW ALLERGIES)
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ANTIBIOTICS
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PAIN MEDS
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IBUPROFEN
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MUSCLE RELAXANT
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ANTI-NAUSEA
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STOOL SOFTENER
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