Approach Denver from the north by southbound I-25 Approach Denver from the west by eastbound I-70

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1 Directions to: Midtown Surgery Center 1919 E. 18th Street Denver, CO From the NORTH: From the WEST: Approach Denver from the north by southbound I-25 Approach Denver from the west by eastbound I-70 > From I-25, take I-70 East to Exit 275C, York. > Take I-70 East to Exit 275C, York. > Go south on York to 18th Avenue. > Go south on York to 18th Avenue. > Turn right onto 18th Avenue (go about 4 blocks). > Turn right onto 18th Avenue (go about 4 blocks). > Turn right into Midtown parking lot just past High Street. > Turn right into Midtown parking lot just past High Street. From the SOUTH: From the EAST: Approach Denver from the south by northbound I-25 Approach Denver from the east by westbound I-70 > From I-25, take Colorado Boulevard North at Exit 204. > From I-70, take Exit Colroado Boulevard South. > Take this to 17th Avenue (3 blocks north of Colfax Avenue). > Take this to 17th Avenue (1st stoplight past City Park). > Turn left (West) onto 17th Avenue, staying in the right lane. > Turn right (West) onto 17th Avenue, staying in the right At Josephine Street the road jogs right. Go straight through lane. At Josephine Street the road jogs right. Go straight the light. You will now be on 18th Avenue. through the light. You will now be on 18th Avenue. > Four blocks after Josephine Street - Midtown is on the right. > Four blocks after Josephine Street - Midtown is on the right.

2 Please Note: Your surgery time is subject to change. Please make yourself available all day. Thank you!

3 NO FOOD OR LIQUIDS (Includes no water, candy, gum, breath mints ---NOTHING) AFTER MIDNIGHT! If you have anything by mouth after 11:59 p.m., We will have to CANCEL YOUR SURGERY!! Western Orthopaedics, PC ***Morning of surgery **IMPORTANT** Morning of surgery*** Please brush teeth with toothpaste, rinse and spit. NO gargling. TAKE ONLY the following medications with ONE SIP of water:

4 ASPIRIN/BLOOD THINNER PROTOCOL FOR PATIENTS NORMALLY TAKING COUMADIN, WHO HAVE NOW BEEN ASKED TO SUBSTITUTE WITH LOVENOX IT IS REQUESTED THAT YOU DISCONTINUE THE LOVENOX A MINIMUM OF 24 HOURS PRIOR TO SURGERY, OR THERE IS A POSSIBILITY YOUR SURGERY WILL BE CANCELLED. DO NOT TAKE ASPIRIN OR ASPIRIN RELATED PRODUCTS FOR TWO (2) WEEKS PRIOR TO YOUR SURGERY - BELOW IS A LIST FOR YOUR CONVENIENCE. The taking of aspirin and/or aspirin related medications can prove harmful to your body's perioperative healing process. Aspirin chemically inhibits the ability of the body to form stable clots necessary to permit proper healing. If you are currently taking any medication and are unsure as to whether it contains aspirin or has a similar effect as aspirin (preventing the formation of stable blood clots), please do not hesitate to contact your pharmacist for additional information. 4-Way Cold Tabs Actron Advil Caps and Tabs Aleve Alka Seltzer Plus Night-Time Cold Medicine Alka Seltzer Plus Cold Medicine Alka Seltzer Extra Strength Alka Seltzer (Flavored) Alka Seltzer Antacid/Pain Reliever Anacin Analgesic Caps & Tabs Anacin Maximum Strength Tabs Anacin Arthritis Pain Formula Anaprox Ansaid Ascriptin w/codeine Tabs Axotal B-A-C #3 Tabs Bayer Aspirin Tabs & Caps Bayer Maximum Aspirin Tabs & Caps Bayer 8 Hour Time Release Aspirin Bufferin Analgesic Tabs Bufferin Arthritis Strength Tabs Carisoprodol Compound Tabs Cataflam Children's Chewable Aspirin

5 Clinoril N-saids Damason-P Norgesic Forte Tabs Darvon with ASA Norgesic Tabs Darvon-N with ASA Nalfon Daypro Nabumetone Dia-Gesic Improved Naprelan Diclofenic Sodium Potassium Naproxen Disalcid Naproxen Sodium Dolobid Naproxyn Dolobid #3 Tabs Nuprin Tabs Easprin Orphengisc w/caff & Aspirin Ecotrin Orudis Ecotrin Max Strength Tabs Oxycodone w/aspirin tabs Empirin with Codeine Oruvail Equagesic Tabs Oxaprozin Etodolac Percodan Tabs & Demi Tabs Feldene Persistins FenoproFen Piroxicam Fiogesic Tabs Regular strength tabs Fiorinal Tabs & Caps Relafen Fiorinal with Codeine Caps Robaxisal Tabs Geiprin Tabs Roxiprin Tabs Ibuprofen Tabs Rulen Tabs Indocin Salflex Indomethacin Salicylate s Ketoprofen Soma Compound Tabs w/codeine Lodine Soma Compound Tabs Lortab ASA Tabs Sulindac Medipren Tabs & Caps Supac Midol 200 Synalgos DC Tabs Motrin Talwin Motrin 200 Talwin Compound Motrin Tabs Tolmetin Mobic Tolectin Meloxicam Tolectin DS or 600 Trilisate Vanquish Analgesic Caps You may take Tylenol, Anacin 3 or Datril as they do not contain aspirin. Attention Men: Please discontinue any erectile dysfunction medications 1 week prior to surgery.

6 IF YOU ARE TAKING ANY OF THESE HERBAL SUPPLEMENTS (LISTED BELOW), WE ASK THAT YOU STOP TAKING THEM PRIOR TO YOUR SURGERY. THE DESIGNATED STOP TIME IS LISTED NEXT TO EACH INDIVIDUAL SUPPLEMENT. ECHINACEA : STOP 2 WEEKS PRIOR TO SURGERY EPHEDRA : STOP 24 HOURS PRIOR TO SURGERY GARLIC: STOP 7 DAYS PRIOR TO YOUR SURGERY. THIS DOES NOT MEAN GARLIC IN YOUR FOOD. GINKGO : STOP 36 HOURS PRIOR TO YOUR SURGERY GINSENG : STOP 7 DAYS PRIOR TO YOUR SURGERY KAVA : STOP 24 HOURS PRIOR TO SURGERY ST. JOHN S WART : STOP 5 DAYS PRIOR TO SURGERY VALERIAN : STOP 2 WEEKS PRIOR TO SURGERY FLAX SEED OIL, VITAMIN E AND FISH OIL : STOP 2 WEEKS PRIOR TO YOUR SURGERY ANY TYPE OF DIET PILLS (METABOLIFE, HERBALIFE, ETC): YOU MUST STOP TAKING 2 FULL WEEKS PRIOR TO SURGERY. IT WAS RECENTLY REPORTED THAT THESE HERBAL SUPPLEMENTS MIGHT CAUSE HARM DURING AND/OR AFTER SURGERY. THANK YOU FOR YOUR COOPERATION AND ALLOWING US TO KEEP PROVIDING YOU WITH THE BEST CARE.

7 SPECIAL NOTICE If you are taking any non-prescription diet medications such as Metabolife or Herbalife, quit taking these at least 3 weeks prior to your surgery/procedure If you are taking any of the following herbal medications: Echinecea, Ephedra, Garlic, Vit. E, Ginkgo, Ginseng, Kava, St. John s Wort, or Valerian, quit taking these medications at least 2 weeks prior to your surgery/procedure.

8 Monday, Oct. 09, 2000 A Dangerous Mix By Ian K. Smith, M.D. Doctors have never quite figured out what to say about herbal supplements. While alternative medications have become increasingly popular--americans will spend some $5 billion this year on natural remedies for everything from arthritis to the common cold--most physicians assumed that even if they didn't know exactly what these remedies did, they were, at worst, harmless. But more and more, doctors are starting to recognize that many natural supplements have medicinal qualities that can complement--or conflict with-- the treatments and medications they prescribe. The American Society of Anesthesiologists is the latest physicians' group to sound a warning about the potential side effects of alternative medications. Concerned by evidence that some supplements can interfere with anesthesia, the group has issued a recommendation that patients stop taking all natural remedies at least two weeks before surgery--giving the body plenty of time to clear them from the system. The anesthesiologists' warning is based on the latest of several findings that are raising doctors' awareness of the risks associated with natural supplements. Take, for instance, ginkgo biloba, used by almost 11 million Americans to improve memory and increase blood circulation. Doctors now believe ginkgo may reduce the number of platelets in the blood and can prevent blood from clotting properly. Taking ginkgo at the same time one is taking blood-thinning medications, like Coumadin or even aspirin, could make a patient dangerously vulnerable to bleeding. Similarly, St. John's wort, a popular supplement taken to treat anxiety, depression and sleep disorders, is believed to prolong or increase the effects of some narcotic drugs and anesthetic agents. Ginseng, an herb taken to boost vitality, has been associated with high blood pressure and rapid beating of the heart-- conditions that could be deadly in the operating room. Part of the problem is that herbal supplements and mainstream medicine come from two very different worlds and operate in different regulatory environments. The marketing of prescription and over-thecounter drugs is strictly regulated by the Food and Drug Administration, which requires scientific proof of safety and efficacy. Herbal remedies, by contrast, are largely exempt from FDA supervision. Companies can sell herbal preparations without guaranteeing that what's on the label is inside the bottle. These uncertainties don't mean that you should never take a supplement. But they make it even more important that you discuss whatever you are taking with your physician--something not enough patients do. A recent study showed that although 60 million Americans have taken alternative medicines, only a third of them reported it to their doctors. This is a bad idea. A drug your doctor prescribes could be perfectly safe and effective, but if you are taking a similar-acting supplement, there is a real danger of cross-reaction. Don't be afraid to bring your herbal supplements to your doctor's office. Your physician may spot a potential conflict on the label or know of another drug--or even another supplement--that works just as well. Dr. Ian appears on WNBC-TV in New York City. him at ianmedical@aol.com For more on herbals, try altmed.od.nih.gov Find this article at:

9 SURGICAL ASSISTANT NOTIFICATION FORM Please be informed that a surgical assistant S.A. or a Physician Assistant P.A. may be required for the proper performance of the operation you need. Surgical assistants and Physician Assistants are professional members of the health care team, and are qualified by academic and clinical education to provide assistance to your surgeon during surgery. If your doctor feels that an assistant is necessary for your procedure, he will use one (some procedures require two assistants), even if your insurance company does not recognize this as a medical necessity. The insurance company will be billed first by the surgical assistant. If your insurance company denies the assistant surgeon, (per our agreement with these assistants) the maximum you are required to pay (per assistant) is $150 for the first hour and $20 for each additional 15 minutes. If your insurance company pays for the surgical assistant-the above agreement does not apply. Note: Most insurance companies consider assistant surgeon s out of network providers or will not even contract with an assistant surgeon. Once you receive a bill from the outside surgical assist company please direct any questions to their billing department. Again the assistant surgeon company is aware of the above agreement and will correct your bill accordingly. Please do not contact our billing department regarding an outside surgical assistant. Below is a list of assistants we use: Surgical Assist Name Billing Phone# Surgical Assist Name Billing Phone # Roman Bachayev Jose Villasenor Alan Duffy Karen Drozda Andrew Waggoner Ken Gallegos 720/ Bob Fox Antranik Kosyan Bryan Carter Helene Desmarais Chief Griffin Sean Oberlander Chris Irons Vong Zhou Peter Gerald Crenshaw Mikhail Malamud Debra Rittinger Paul Beal Rob Sherwood Mark Mauries Joe Harris Tony Fabre Pedro Peter Rodriguez Scott Comeaux Bridger Cook I have read the preceding information and acknowledge being notified. Patient signature: Printed name: Today s date: Effec 7/16/07 Rev 10/10/07 Rev 5/13/09 Rev 8/1/09 Rev 1/13/10 Rev 9/6/11 REV 1/16/13 REV 11/15/13 rev 05/23/14 rev 7/15/15

10 MIDTOWN SURGICAL CENTER 1919 E. 18th Avenue, Denver, CO (303) Your procedure is scheduled on, at Please arrive at the Center at PRIOR to your procedure date, Midtown Surgical Center will:. Attempt to contact you regarding preparations for your procedure, as well as discuss your rights & responsibilities as a patient, physicians who have ownership in our facility, our grievance process, Advance Directives, and the informed consent process.. Attempt to contact you regarding your insurance and/or your financial obligations. Or, you can call our insurance verification department at (720) PRIOR to your procedure, YOU/THE PATIENT should:. Review the contents of this packet and follow all instructions. If the surgical center has not successfully reached you, please call Midtown Surgical Center at least 3 days prior to your scheduled procedure, between 7:30 am - 4:00 pm, Monday - Friday at (303) or (303) and ask for Capri, our Patient Pre-Operative Case Coordinator.. Please log on to our website ww.midtownsurgicalcenter.com and complete the on-line history form as soon as you are scheduled for your procedure, if you have access to the internet. Please bring this packet of documents with you on the day of your procedure.

11 Midtown ~ Surgical Center i 9 I 9 East 18th Avenue Denver, Colorado 8020(i Phone fax Dear Patient of Midtown Surgical Center, As a Medicare licensed surgery center, we are federally required to provide in writing, as well as discuss with you the following information prior to your procedure: your rights & responsibilities as a patient, physicians who have ownership in our facility, Advance Directive information, our grievance process and the informed consent process. Inside this envelope, you will find all the written information we are federally mandated to communicate to you. Please read it, complete and sign the necessary documents, and bring all of it with you to the surgery center on your surgical day. If you have not heard from Midtown Surgical Center within two (2) days of your procedure, please call us so that we can go over this information with you. Our business hours are 7am - 4pm, Monday through Friday. Please call (303) or (303) and ask for Capri. Thank you in advance, Midtown Surgical Center

12 Midtown ~ Surgical Center ll) I l) East i 8th Avenue Denver, Colorado 8020Ei l13 Phone fax Welcome to Midtown Surgical Center. We're very pleased that you and your physician have chosen us to care for you. We recommend that you enter your medical history online as soon as your surgery has been scheduled. Once you do this, our nursing staff will be able to access the information you entered online. This information will assist nursing staff in organizing and documenting your complete medical history to prepare for your surgery. To begin, 1) Go to our website: 2) Select "Medical History" on the front page. 3) Click "One Medical Passport" 4) Accept the terms of use and click "Register" 5) Complete the registration and medical history screens, click Finish to submit your Medical Passport to the medical facility Be sure to have the following information available before starting your Medical Passport: Your health insurance information.. The names, addresses and phone numbers of your physicians.. A list of all medications you are taking, their dosage and frequency.. A list of surgical procedures you have ever had and their approximate dates.. This is a secure web site shared only with your treatment team.. Returning patients will be able to update an existing passport at any time. Note: If you are not able to complete your history online, please call our Preoperative case coordinator Capri between 7:30 and 4:00 Monday-Friday at (303) or (303) as soon as possible to complete your health history. You wil stil need to have the above information available when you call. Please allow minutes for this call.

13 Midtown Surgical Center RIGHTS OF PATIENTS The medical staff and personnel of Midtown Surgical Center recognize the basic human rights of patients. Efforts are directed to providing care commensurate with those basic human rights. Patients have the right to:. Be infonned of his or her rights as a patient in advance of receiving care. The patient may appoint a representative to receive this infonnation should he/she so desire.. Exercise these rights without regard to sex or cultural, economic, educational or religious background or the source of payment for care.. Considerate, respectful and dignified care, provided in a safe environment, free from all fonns of abuse, neglect, harassment and/or exploitation.. Access protective and advocacy services or have these services accessed on the patient's behalf.. Appropriate assessment and management of pain.. Knowledge of the name of the physician who has primary responsibility for coordinating his/her care and the names and professional relationships of other physicians and healthcare providers who will see him/her. The patient has a right to change providers if other qualified providers are available.. Be advised if the physician has a financial interest in the surgery center. A list of physician investors is available upon the patient's request. The doctor perfonning your procedure at Midtown Surgical Center has a financial interest in this facility.. Be advised as to the absence of malpractice coverage.. Receive complete infonnation from his/her physician about his/her diagnosis, illness, course of treatment, risks, benefis, alternative treatments, outcomes of care (including unanticipated outcomes), and his/her prospects for recovery in tenns that he/she can understand. Your physician should discuss these with you prior to the procedure and give you the opportunity to ask any questions you may have.. Receive as much infonnation about any proposed treatment or procedure as he/she may need in order to give infonned consent or to refuse the course of treatment. Except in emergencies, this infonnation shall include a description of the procedure or treatment, the medically significant risks involved in the treatment, alternate courses of treatment or non-treatment and the risks involved in each and the name of the person who will carry out the procedure or treatment.. Participate in the development and implementation of his/her plan of care and actively participate in decisions regarding his/her medical care. To the extent permitted by law, this includes the right to request and/or refuse treatment.. Be infonned of the facility's policy and state regulations regarding advance directives and be provided advance directive infonnation, if requested.. Full consideration of privacy concerning his/her medical care. Case discussion, consultation, examination and treatment are confidential and should be conducted

14 discreetly. The patient has the right to be advised as to the reason for the presence of any individual involved in his/her healthcare.. Confidential treatment of all communications and records pertaining to his/her care and his/her stay at the facility. His/her written permission will be obtained before his/her medical records can be made available to anyone not directly concerned with his/her care.. Receive information in a manner that he/she understands. Communications with the patient will be provided in a manner that facilitates understanding by the patient. Written information provided will be appropriate to the age, understanding and the language of the patient. Communications specific to the vision, speech, hearing cognitive and language-impaired patient will be appropriate to the impairment.. Access information contained in his/her medical record within a reasonable time frame.. Be advised of the facility's grievance process, should he or she wish to communicate a concern regarding the quality of care he or she receives. The patient can file a grievance with the facility's Administrator or Clinical Operations Manager at (303) ; or the patient can file a grievance with the Colorado Department of Public Health and Environment at 4300 Cherry Creek Drive South, Denver, CO at (303) Be advised of contact information for the state agency to whom complaints can be reported, as well as contact information for the Offce of the Medicare Beneficiary Ombudsman. WW. cms. hhs.gov/center/om budsman. asp. Be advised if facility/personal physician proposes to engage in or penorm human experimentation affecting his/her care or treatment. The patient has the right to refuse to participate in such research projects. Refusal to participate or discontinuation of participation will not compromise the patient's right to access care, treatment or services.. Full support and respect of all patient rights should the patient choose to participate in research, investigation and/or clinical trials. This includes the patient's right to a fully informed consent process as it relates to the research, investigation and/or clinical trial. All information provided to subjects will be contained in the medical record or research file, along with the consent form(s).. Be informed by his/her physician or a delegate of his/her physician of the continuing healthcare requirements following his/her discharge from the facility.. Examine and receive an explanation of his/her bill regardless of source of payment.. Know which facility rules and policies apply to his/her conduct while a patient.. Have all patient rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.. All facility personnel, medical staff members and contracted agency personnel penorming patient care activities shall observe these patients' rights. Pt Initials

15 RESPONSIBILITIES OF PATIENTS The care a patient receives depends partially on the patient him/herself. Therefore, in addition to these rights, a patient has certain responsibilities as well. These responsibilities are presented to the patient in the spirit of mutual trust and respect:. The patient has the responsibility to provide accurate and complete information concerning his/her present complaints, past illnesses, hospitalizations, medications (including over the counter products and dietary and herbal supplements) and dosages, allergies and sensitivities, and other matters relating to the patient's health.. The patient and family are responsible for asking questions when they do not understand what they have been told about the patient's care or what they are expected to do.. The patient is responsible for following the treatment plan established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician's orders. It is the patient's responsibility to notify the facility if he/she has not followed the pre-operative instructions given by their physician and/or facility personnel.. The patient is responsible for keeping appointments and for notifying the facility or physician when he/she is unable to do so.. Provide a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours unless exempted from that requirement by the attending physician.. In the case of pediatric patients, a parent or legal guardian must remain in the facility for the duration of the patient's stay in the facility.. The patient is responsible for his/her actions should he/she refuse treatment or not follow his/her physician's orders.. The patient is responsible for assuring that the financial obligations of his/her care are fulfilled as promptly as possible. Ultimate financial responsibility is the patient's, regardless of the insurance coverage he/she may have.. The patient is responsible for following facility policies and procedures.. The patient is responsible to inform the facility about the patient's Advanced Directives.. The patient is responsible for being considerate of the rights of other patients and facility personnel, to include being respectful of his/her personal property and that of other persons in the facility.. Patient's signature represents he/she has received written and verbal information regarding physicians' financial interest in the Facility, Advance Directives, grievance process and on the informed consent process prior to the day of their procedure. Patient Signature: Date:

16 MIDTOWN SURGICAL CENTER PATIENT CONSENT TO RESUSCITATIVE MEASURES NOT A REVOCATION OF ADVANCE DIRECTIVES OR MEDICAL POWERS OF ATTORNEY ALL PATIENTS HAVE THE RIGHT TO PARTICIPATE IN THEIR OWN HEALTH CARE DECISIONS AND TO MAKE ADVANCE DIRECTIVES OR TO EXECUTE POWERS OF ATIORNEY THAT AUTHORIZE OTHERS TO MAKE DECISIONS ON THEIR BEHALF BASED ON THE PATIENT'S EXPRESSED WISHES WHEN THE PATIENT IS UNABLE TO MAKE DECISIONS OR UNABLE TO COMMUNICATE DECISIONS. THIS SURGERY CENTER RESPECTS AND UPHOLDS THOSE RIGHTS. HOWEVER, UNLIKE IN AN ACUTE CARE HOSPITAL SETIING, THE SURGERY CENTER DOES NOT ROUTINELY PERFORM "HIGH RISK" PROCEDURES. MOST PROCEDURES PERFORMED IN THIS FACILITY ARE CONSIDERED TO BE OF MINIMAL RISK. OF COURSE, NO SURGERY IS WITHOUT RISK. YOU WILL DISCUSS THE SPECIFICS OF YOUR PROCEDURE WITH YOUR PHYSICIAN WHO CAN ANSWER YOUR QUESTIONS AS TO ITS RISKS, YOUR EXPECTED RECOVERY AND CARE AFTER YOUR SURGERY. THEREFORE, IT IS OUR POLICY, REGARDLESS OF THE CONTENTS OF ANY ADVANCE DIRECTIVE OR INSTRUCTIONS FROM A HEALTH CARE SURROGATE OR ATIORNEY IN FACT, THAT IF AN ADVERSE EVENT OCCURS DURING YOUR TREATMENT AT THIS FACILITY WE WILL INITIATE RESUSCITATIVE OR OTHER STABILIZING MEASURES AND TRANSFER YOU TO AN ACUTE CARE HOSPITAL FOR FURTHER EVALUATION. AT THE ACUTE CARE HOSPITAL FURTHER TREATMENT OR WITHDRAWAL OF TREATMENT MEASURES ALREADY BEGUN WILL BE ORDERED IN ACCORDANCE WITH YOUR WISHES, ADVANCE DIRECTIVE OR HEALTH CARE POWER OF ATTORNEY. YOUR AGREEMENT WITH THIS POLICY BY YOUR SIGNATURE BELOW DOES NOT REVOKE OR INVALIDATE ANY CURRENT HEALTH CARE DIRECTIVE OR HEALTH CARE POWER OF ATIORNEY. IF YOU DO NOT AGREE TO THIS POLICY, WE ARE PLEASED TO ASSIST YOU TO RESCHEDULE THE PROCEDURE. PLEASE CHECK THE APPROPRIATE BOX IN ANSWER TO THESE QUESTIONS. HAVE YOU EXECUTED AN ADVANCE HEALTH CARE DIRECTIVE, A LIVING WILL, A POWER OF ATTORNEY THAT AUTHORIZES SOMEONE TO MAKE HEALTH CARE DECISIONS FOR YOU? o YES, I HAVE AN ADVANCE DIRECTIVE, living WILL OR HEALTH CARE POWER OF ATIORNEY. o No, I DO NOT HAVE AN ADVANCE DIRECTIVE, living WILL OR HEALTH CARE POWER OF ATIORNEY. o I WOULD LIKE TO HAVE INFORMATION ON ADVANCE DIRECTIVES. IF YOU CHECKED THE FIRST BOX "YES" TO THE QUESTION ABOVE, PLEASE PROVIDE US A COpy OF THAT DOCUMENT SO THAT IT MAY BE MADE A PART OF YOUR MEDICAL RECORD. BY SIGNING THIS DOCUMENT, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS CONTENTS AND AGREE TO THE POLICY AS DESCRIBED. IF I HAVE INDICATED I WOULD LIKE ADDITONAL INFORMA TlON, I ACKNOWLEDGE RECEIPT OF THA T INFORMA TlON. BY: (PATIENT'S SIGNATURE) Patient's Last Name: Patient's First Name: Date: If consent to the procedure is provided by anyone other than the Patient, this form must be signed by the person providing the consent or authorization. I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS CONTENTS AND AGREE TO THE POLICY AS DESCRIBED. BY: (Signature) (Print Name) Relationship to Patient o COURT ApPOINTED GUARDIAN 0 ATIORNEY IN FACT o HEALTH CARE SURROGATE 0 OTHER Midtown Surgical Center Patient Consent to Resuscitative Measures

17 DEMOGRAPHIC INFORMATION Name: Home Phone: Emergency Contact Date of Birth: Age: Work Phone: Name: Sex: Mobile Phone: Phone: Height: Name of Person Weight: Address: Completing Form: Age: Phone: BMI: Legal Guardian: I. Yes i No Primary Language: Needs Translator: Primary Care Physician: Phone: Specialist: Phone: Specialty: Specialist: Phone: Specialty: Specialist: Phone: Specialty: RIDE HOME INFORMATION Name: Relationship: Phone: Name of person who will care for patient after suroerv: PREOPERATIVE INFORMATION AND EVALUATION Planned Procedure: Scheduled Date of Procedure: Suroeon: Current Prescription and Nonprescription Medications (include over the counter and vitamins) Medication Dose Frequency Reason Medication Dose Frequency Reason Allergies Medication Allergies Reaction(s) Other Allergies Reaction(s) Latex Products? Adhesive Tape? IV Contrast I xray dye? Environmental Allergies? Food Allergies? Surgical/Anesthesia History Surgery Date (approximate) Problems o Malignant Hyperthermia 0 Pseudocholinesterase Deficiency 0 Postoperative nausea and vomiting (PONV) o Motion Sickness 0 Other (ê Medic;:l Web Technoloaies LLC

18 Patient Name/DOB: Cardiovascular REVIEW OF SYSTEMS D Angina D Myocardial infarction D Congestive heart failure D Abnormal heart rhythm D High blood pressure D Heart valve problems D Vascular disease D Pacemaker D Implanted Defibrillator D High cholesterol or lipids D Coronary Stents D Bypass surgery D Other Pulmonary Renal D Emphysema/COPD D Asthma D Pneumonia D Home oxygen use D Sleep apnea D Tuberculosis D CPAP D Bronchitis D Shortness of Breath D Recent cough/cold D Smoker _ppd D Other D Kidney stones D Prostate trouble D Urinary incontinence D Kidney failure D Dialysis D Other Hepatic D Liver failure or yellow jaundice D Hepatitis D Cirrhosis D Alcohol use drinks/day D Other Neurological Gastrointestinal Hematological Endocrinel Metabolic Musculoskeletal Psychiatric D Seizures D Stroke D Neuropathy D Frequent migraines that require treatment D Paralysis D Alzheimer's D Parkinson's D Other D Stomach ulcers D Frequent acid reflux or heartburn D Hiatal hernia of the stomach D Other D Anemia D Bleeding or blood clotting disorders D Blood transfusion D AIDS D Recent use of blood thinners D Other D Thyroid Disease D Cancer(s): D Insulin Dependent Diabetes D Non-Insulin Dependent Diabetes D Other D Musculoskeletal Problems D Arthritis D Chronic low back pain D Neck/Jaw problems D Muscular Dystrophy D Implants/Joint replacement: Where D Other D Bipolar disorder D Schizophrenia D Depression D Panic/anxiety attacks D Other OB/Gyn D Currently pregnant D Hysterectomy D Bilateral Tubal Ligation DNA Last Menstrual Period Date: Other D Glasses/Contact Lenses D HearinQ Aids D Chronic Pain, Pain Score: (1-1 Q) D Dental work: D Dentures D Bridges D Caps/crowns D Chipped/loose teeth Illicit Drug History or Drug History (Marijuana, cocaine, etc.): Contagious D MRSA, Date:, How Treated: Diseases D Other D None Child D Normal growth and development D Abnormalities - Explain: Additional Comments or History Not Addressed: Patient Signature: Date: Nurse Signature: Date: Comments: This report is not intended to be added to the medical record, please enter this information into SourcePlus Passport and print a Medical Passport for this patient. (Q 2011, Medical Web Technologies, LLC

19 ~ l\lidtown Surgical Center Financial Responsibilty Agreement PATIENT RESPONSIBILITY: Any fees collected at the time of service and any quotes regarding such fees are estimated based on the information available to us at the time of service. We rely on information provided by the responsible party regarding insurance coverage, information from the responsible party's insurance company, and procedure fees associated with the CPT codes scheduled/reserved and provided to us by your surgeon. This estimate does not include the fees for the physician or anesthesiologist. There may be additional charges should your surgeon perform a procedure that is different from, or in addition to, what was scheduled, or for x-rays, implants, 23-hour observation, or other services which were not scheduled or quoted prior to surgery. PLEASE NOTE: It is the patient's responsibilty to understand their individual insurance benefits. PAYMENT ARRANGEMENTS: Payment arrangements are available. Please ask about this option if you are interested. Any payment arrangements should be arranged prior to services being provided. BILLING PRACTICES: Midtown Surgical Center will bill the responsible party's insurance company for facility charges. Midtown Surgical Center will also collect any co-payments, co-insurance, and/or deductibles at the time of service. The responsible party will be billed for any remaining charges not covered by insurance, including co-payments, co-insurance and/or deductibles. Additionally, the responsible party will be billed for facility charges in full should the insurance company deny coverage due to lack of referral, no pre-authorization, lack of proper reporting of incident/accident or lack of individual coverage, where applicable. COLLECTION ACTIVITY: Any account balance that is not paid within 90 days of the date of service may be forwarded to an outside agency for collection follow-up. Any account balance that remains unpaid after this transfer may be eligible for reporting to a credit bureau. Should litigation be necessary to collect an outstanding balance owed, the responsible party agrees to pay all costs of collection including, but not limited to, collection fees, attorney fees, interest and court costs. If you have any questions, please contact the Central Business Offce at (720) Thank you for choosing Midtown Surgical Center. Patient/Responsible Party: Date:

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22 SURGERY DO'S AND DON'T'S DON'T eat or drink anything after midnight the night before your surgery (unless otherwise instructed by your Dr. or anesthesiologist) DON'T wear any jewelry or contact lenses, please wear your glasses. Wear loose fitting, comfortable cloths. DON'T forget to bring all your paperwork, photo ID and insurance card. DO take your blood pressure or heart medication with just a sip of water the morning of your surgery (unless otherwise instructed by your Dr.) DO stop all herbal supplements and diet pills 2 weeks before surgery. If you take blood thinners contact your surgeon for instructions. DO contact your surgeon or PCP if you are diabetic, for instructions on when to take your medications. DO get crutches if needed-we DO NOT provide them. DO make sure you have a ride home after your surgery and if you will be having general anesthesia, you will need someone to stay the night with you after your surgery. DO YOU HAVE AN ALLERGY TO LATEX CONFIRM TIMES ONL Y WITH YOUR SURGEON! PEDIATRIC PTS- No Consent to Resuscitate necessary and PARENT MUST be present in the facility throughout the procedure. Please call us at Midtown Surgical Center with any questions

23 TvEdto,..'o "cc:, Surzi(:al Center "W,-, You concentrate on getting weij...walgreens pharmacywillconctonlrate on giving you top-quality pharmaceutical care. Located atpresbyterianl SLLuke's Medical Center, Professional Plaza West (4th Floor), we offer you an exceptional level of individualize service-ihcluding delivery of medications to yourhospftalroom!* Walgreens pharmacy at Professional Plaza West (4th Floor) 1601 E. 19th Ave., Suite 4650 Phone: 303c Fax: Pharmacy Manager: Katey Morris Delivery Hours: Monday through Friday, S a.m. to 6 p.m. Delivered within two hours of request. Nearest 24-hour Walgreens Location 2000 L Colfax Ave. I ntersection:colfaxand Race Phone: Oe17 Fax: No bedside deliveries from this location. Fill in the information requested below and your nurse or case manager can fax in your prescriptions with this form directly to our pharmacy. Thank you for choosing Walgreens. Name Date of Birth Physician's Name Prescription Insurance Plan Is there a caregiver/family member who you grant permission to assist you with your pharmacy needs? (if applicable) Caregiver Name ~ ~ ~ Caregiver Phone Number Payment Information Credit ca rd num ber Exp. date ~ ~ Please provide payment upon delivery. Check One: 0 Bedside delivery o Pickup at Walgreens located at Presbyterian/St. Luke's Medical Center o Delivery needed by Have you had a prescr'iption fiiled at any Walqreeri~, in riie past 12 months? Circle one: Yes No Home Address City, State Home or Cell Phone Number List Any Drug Allergies PACU Phone: Nurse zip CONFIDENTIAL HEALTH INFORMATION: Healthcare information is personal information related to a person's healthcare. It is being faxed to you after appropriate authorization or uncer circurr- :::3r'r~-:'s I:-.c:l,::i)r;'l r::qu:re i)i:t~,i)ri2cjl:c,li. YJli em:' o:.ii:;l1i,:,ct 1.,) rr~ir,tair' :t in.ì s,)f::, S~:'C'Jri~.Jr~d cc,n~-í,::.:,ntìa: 'ii.,ji';n~t R,:.d:::c-l~;:L.r~ of th.s ir',.:,r,i,~~tii)r~ ;s pr:;rl:ijlli:,j '.,11:(-5:; ri.:;rr:iiu":~ 1.:1,,. ':'1' a~,pr:)p'ï;.j:'2 :"i.,.i:t.:,rr(-r/p,'l~i..~~t,;~:tr.'jri7rjti(jr,:~ (l:: tni,-,i:d Uriat:thc,riz,:;ri t(-di:;c::r;s\:r(" or ~;I~:rf t:i,ì).ìint.:iin CQr,fjdC',-,ti;::i~y ((';";10 ~Lrb;c-r.t V:lll tn :'F.n ft:f:~ rj(":;nilj?,j ii, j~,jer.'ll?i",rj st?tf law:., ~~,~(~ ~:: ZiT ~~:~ i~.~~ ~~~,:11it ~ ~~~~~'~~~.; \t~. ~~r~~~: :,~,~:~~ ~~ L~~\ '~~, ~';i~ t~~.i~~'.~ ~~'r~:;~; ~i ~t, t~ r ~~ ~r;"~\i\~~~~;î~:;/~~~ r~~ifì ~~:~~~r~, ~ ~:~:';.')i~ri ~i~;~'r'~:~~it~~:~ t t ~'~~. ~.: ~'~~~ ~~~;~jci r ~~ ;jn ~~)~~j I~,~~ t ~~~ ~~:r~i~,~c ~~::t~f~~j dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this rr.essaqe in error, please notify us irrrrediately. cz:jí.clio'..vqi'.~rc~.~nc:j. A;r,-Î'.ht.~l~sC-r' c~d. Of'!4C:3~; :1:8

24 Discharge Medication Patient Information and Choice Letter Dear Patient and Family: Your physician has ordered medication for you after you leave the hospital. Walgreens pharmacy, which is located in the Professional Plaza West on the 4th floor, can fill and deliver the medications to your bedside, after your doctor decides to discharge you from Midtown Surgical Center. Please note that you have the right to select any pharmacy to provide the medications ordered by your physician. This service is provided as a convenience to you. This is your choice. If at a later date you choose to move your prescription to another pharmacy, Walgreens will assist you in this process. If you need more information before making this decision, please ask one of our nursing staff on the unit. If you wish to use the bedside delivery option please fill out the form below and give it to your nurse. Your nurse will send the prescriptions to the pharmacy and they will deliver them to your room. Patient or Family: Please complete the following: i hereby choose to use Walgreens Pharmacy Walgreens Pharmacy at Professional Plaza West (4th Floor) 1601 E. 19th Ave., Suite 4650 Phone: 303~ Fax: Nearest 24-Hour Walgreens Location 2000 E. Colfax Ave. Intersection: Colfax and Race Phone: Fax: Patient Signature: Date: Family Member / Guardian Signature: Relationship: Date: Thank you for choosing Midtown Surgical Center for your healthcare needs! (03/10).. Midtown He.ilth Surgical Center

25 Your anesthesiologist will make every effort to contact you the night before your surgery. Please assist us by ensuring that your contact information is correct and your phone will accept blocked calls. If for some reason we are unable to reach you, please visit our website or call our office at with questions. Thank you and we look forward to caring for you! Revised April 2015