Patient's Name *

First Name

Last Name

Surgery Date *

MM

DD

YYYY

When do you want your prescriptions sent to your pharmacy *

Please tell us when you want us to send your prescriptions to your pharmacy

Please send my prescription in one to two days before my surgery

Please send my prescription after my surgery when I am discharged from the hospital

Your Phone Number

Please provide a phone number in case we need to contact you about your prescription

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Pain Medicine

Taking pain medicine after surgery is optional, and all patients should try to wean themselves off pain medicines as soon as possible.

Percocet (oxycodone), 5/325, take 1-2 every 6 hrs as needed, #30

Norco (hydrocodone), 5/325, take 1-2 every 6 hrs as needed, #30

Tramadol, 50 mg, take 1-2 every 6 hours as needed, #30

I don't need a pain medication prescription

I need a different pain medication prescription. (please write a note in the free text field below)

Blood Thinner

Taking blood thinners after surgery is required. Most patients without a history of blood clots take aspirin. Most patients with a personal or family history of blood clots (DVT/PE) should take Xarelto or Eliquis.

Aspirin, 81 mg, take 1 twice a day, #60 (4 weeks)

Xarelto, 5 mg, take 1 once a day (4 weeks)

Eliquis, 2.5 mg, take 1 once a day (4 weeks)

I am already on a blood thinner

I need a different blood thinner prescription

Nausea Medication

Taking nausea medication after surgery is optional.

Zofran, 4 mg, 1 every 4 hours as needed, #10

Phenergan, 25 mg 1 every 6 hours as needed, #10

I don't need nausea medicine

NSAID

Taking a non-steroidal anti-inflammatory medication (NSAID) after surgery is optional. Many patients do not tolerate NSAIDs because of heart, kidney, stomach or blood pressure issues. If you tolerate NSAIDs, then taking an NSAID can help relieve post operative pain and limit narcotic usage.

Celebrex, 200 mg, take 1 twice a day, #60

Mobic, 15 mg, take 1 twice a day, #60

Naprosyn, 220 mg, take 1 twice a day

Ibuprofen, 800 mg, take 1 three times a day, #90

I can't take NSAIDs

I already have NSAIDs or get them myself

Antibiotic

Taking an oral antibiotic after surgery is optional. If you are sensitive to antibiotics, then I would recommend against taking an antibiotic.

Keflex, 500 mg, take 1 every 8 hrs, #21

Doxycycline, 200mg, take 1 every 12 hrs, #14

I do not tolerate antibiotics

I prefer a different antibiotic

Flomax

Some patients with urinary retention struggle to urinate after surgery. Taking Flomax for 3 days before and 3 days after surgery can sometimes help.

Flomax 0.4mg, take 1 before bedtime, #7

I don't need a urinary retention prescription

I already have a prescription for Flomax