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
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.