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Across the United States, approximately 2.3 million people become ill or have adverse side effects from medical therapy each year. Also, adverse drug events account for about 4.7% of US hospital admissions and contribute to an estimated $3.8 million in costs per hospital each year.

Here at Simi Surgery Center we take medication delivery very seriously. We believe that you, the patient, are a key member of the team that needs to be involved in enhancing accuracy of your treatment. In order to provide the highest quality safe care, we would like to document the most accurate and complete list of your current medications. This would include the name, dose and frequency of each medication you take.

Since this information is detailed and may be difficult to remember, we ask you to bring all current medication bottles (including multi-vitamins, herbals, special creams or lotions, laxatives, and any other over-the-counter remedies you take) with you when you come for your surgery. If you are unable to bring in the bottles, please bring in an updated medication list including all of the above information.

When you arrive at the ASC, you will be asked to review the information we have regarding your medications in our medical record and to edit it based on your medication bottles or the medication list that you bring in.

When you leave our facility, we will give you an updated list of your medications for you to take to your next provider of care.

We are dedicated to providing the highest quality, safest care possible, and we appreciate your partnership to support us in achieving this goal. Please feel free to contact your Doctor with any questions, and print this form for future use for your personal files.

Below you will find a PDF form that you can list your medications. You will need the Adobe Acrobat Reader 7.x or better to open and print the form. If you do not have the Adobe Acrobat Reader 7.x, click on the Acrobat badge below to download. Once the PDF has loaded, save it to your local hard-drive and fill-in the information. When completed, print 2 copies of the completed form and bring with you.


Simi Surgery Center - Medication Reconciliation Form

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