Healthcare Bleph Instructions

HEALTHCARE BLEPH INSTRUCTIONS

These instructions provide pre-operative and post-operative guidance for blepharoplasty (eyelid surgery) and related periocular procedures. The patient is required to read, initial, and follow each applicable instruction. Noncompliance may increase the risk of complication or adversely affect surgical outcome. The patient acknowledges receipt of these instructions and consents to proceed as indicated below.

Patient Information

Patient Name:

Emergency Contact

Insurance Information

Procedure Details

Procedure:

Operative Eye(s): Left Right Both

Surgeon:

Medical History & Current Medications

History of bleeding disorder: Yes No

Tobacco use within last 30 days: Yes No

Pre-Operative Instructions

Please read and initial each instruction. Initialing signifies understanding and agreement to comply.

Initials: No solid food after midnight prior to surgery; clear liquids allowed up to 2 hours before arrival.

Initials: Continue or discontinue medications as directed below.

Remove contact lenses, cosmetics, nail polish, and jewelry the day of surgery. Bring a responsible adult for transportation and post-op care.

Day of Surgery

Arrive at: at scheduled time: .

Expect mild to moderate swelling and bruising. Arrange to rest and avoid heavy lifting for 48–72 hours post-procedure.

Post-Operative Care

Apply cold compresses to the operated area for 15 minutes on and 15 minutes off during the first 48 hours to reduce swelling.

Use prescribed antibiotic ointment as directed. Do not rub or apply pressure to the eyelids. Cleanse with sterile saline or as instructed.

Avoid strenuous activity, heavy lifting, bending, and exercise for at least 2 weeks. Elevate head while sleeping for 7 days.

Warning Signs / When to Call

Contact the clinic or emergency services immediately for any of the following: uncontrolled bleeding, sudden severe pain unrelieved by medication, fever greater than 101.5°F (38.6°C), spreading redness, or significant vision loss.

Risks, Benefits, and Alternatives

I understand the risks associated with blepharoplasty include but are not limited to bleeding, infection, unfavorable scarring, asymmetry, dry eye symptoms, transient or permanent changes in vision, need for revision, and anesthesia-related complications. Expected benefits include improvement in eyelid contour, vision field, and cosmetic appearance. Alternatives include non-surgical treatments, delay of procedure, or no treatment.

I have had the opportunity to ask questions regarding the procedure, risks, benefits, and alternatives. My questions have been answered to my satisfaction.

Photographs and Medical Records

I authorize clinical photography for medical records and treatment documentation. Identifying information will be handled in accordance with privacy practices. I authorize the release of my medical records to other treating providers for continuity of care as necessary.

HIPAA / Privacy Acknowledgment

I acknowledge that I have received the facility's Notice of Privacy Practices and understand that my protected health information may be used for treatment, payment, and healthcare operations as described therein.

Consent to disclosure for appointment reminders and brief clinical information by telephone or text: Yes No

Patient Acknowledgment and Consent

By signing below, I certify that: I have read and understand these instructions; I have provided an accurate medical history; I consent to the procedure described above and to the administration of anesthesia as indicated; I understand I may withdraw consent at any time prior to the procedure and that withdrawal may not be possible once sedation or anesthesia has begun.

Sign Now