Dental Surgery Pre-Operative Checklist
Patient Name
Date of Birth
Surgery Date
Surgeon
Procedure
Medical History
Diabetes
Bleeding Disorders
Heart Conditions
Allergies
Other
Known Allergies
Current Medications
Pre-Operative Checks
Informed Consent Signed
NPO Instructions Given
Vitals Checked
Surgical Site Marked
Radiographs Available
Blood Pressure
Pulse
Temperature
Additional Notes