Plastic Surgery Consent & Checklist
Patient Information
Patient Name
Date of Birth
Procedure
Surgery Date
Surgeon
Pre-Operative Checklist
Fasted as instructed
All medications reviewed
Allergies checked
Consent form signed
Surgical site marked
Valuables removed
Pregnancy test (if applicable)
Consent Statement
Patient Signature
Date
Witness Signature
Date
Surgeon Signature
Date