Tolnitch Surgical Associates, PA
2301 Rexwoods Drive, Ste 116
Raleigh, NC 27607

Lisa Tolnitch, M.D., F.A.C.S.
Nancy Crowley, M.D., F.A.C.S
Gayle DiLalla, M.D., F.A.C.S
Keith D. Amos, M.D.

Telephone: 919-782-8200   Fax: 919-781-0440


Patient’s Name:___________________________________________________________
Hospital:  Rex   Date of Surgery:________________
Time to Report to Hospital:___________________ Time of Surgery:________________
Nuclear Medicine SLNB Injection Time:_________ Needle-Loc Time:______________
Date/Time-Preoperative Testing:_____________________________
I,_________________________________________________consent to the procedure
________________________________________________________________________
________________________________________________________________________

I understand that it is elective. I understand the possible risks and complications. I have had adequate time to ask questions and all have been answered to my satisfaction.

  • DO NOT EAT OR DRINK ANYTHING after midnight the night prior to your surgery. We advise that you wear comfortable clothing- something that you can put back on easily after surgery. You will need someone to drive you home after your surgery if you are an outpatient and to stay with you.
  • ADDITIONAL INSTRUCTIONS/PREP: Stop taking aspirin, BC powders, any aspirin or ibuprofen product, any food with curry powder, vitamin E, herbal supplements: garlic, ginger root, gingko biloba, and feverfew – one week prior to surgery; you may take Tylenol for slight pain or discomfort.
We will file insurance for you if you have provided us with the necessary information. You are responsible for payment on your account. For most insurance plans, we will call for an approval number and file the insurance for the procedure. However, it is your responsibility to understand the coverage and benefits provided by your insurance package. Please call your company or representative with any questions regarding services covered, second opinions, precertification, and patient responsibility.

SIGNED_______________________________________________DATE____________

WITNESS______________________________________________DATE____________