Surgery Medication Discontinuation Form

Patient & Surgery Details

First Name:

Last Name:

Name of Practice:

The Surgery is:

Surgery Date:

Arrive at hospital at:

Your Surgeon will be:

Hospital/Clinic for Surgery:

Surgery Site Phone:

Your Office/Clinic Phone:

Medication & Supplement Selection Form

Select the specific medication the patient takes from the dropdown menus below. Hover over any medication family label to read a brief explanation of its clinical purpose.

1. Prescribed Medications (Alphabetical Order)

2. Over-the-Counter (OTC) Medications (Alphabetical Order)

3. Supplements & Botanicals (Alphabetical Order)

*CRITICAL CLINICAL NOTE: Patients taking Aspirin, Plavix, Brilinta, Coumadin, or DOACs for coronary artery stents, mechanical heart valves, recent stroke, or atrial fibrillation must NEVER discontinue medication without explicit authorization from their managing cardiologist or surgeon.

Clinical Guidelines & References (Not Printed on Report)

The medication and supplement discontinuation intervals utilized in this assessment tool are derived from peer-reviewed anesthesiology, cardiovascular, and surgical consensus guidelines:

American Society of Anesthesiologists (ASA): Practice Guidelines for Preoperative Fasting and Perioperative Medication Management. Recommends discontinuation of non-essential herbal preparations 2 weeks prior to surgery, weekly GLP-1 agonists 7 days prior, and SGLT2 inhibitors 3 to 4 days prior to prevent euglycemic ketoacidosis.
American College of Cardiology / American Heart Association (ACC/AHA): Guideline for the Perioperative Management of Antithrombotic Therapy. Establishes the preoperative cessation windows for P2Y12 inhibitors (5-7 days), Warfarin (5 days), and Direct Oral Anticoagulants (48-72 hours based on renal clearance).
The Iowa Clinic / Waukee Surgery Center & Iowa Ortho: Preoperative Clinical Protocols for Outpatient Surgical Patients. Establishes standardized cessation timelines for anti-inflammatory medications, rheumatology biologics, stimulant weight loss agents, and over-the-counter analgesic preparations.
US Food and Drug Administration (FDA) Drug Safety Communications: Mandates temporary discontinuation of canagliflozin, dapagliflozin, and empagliflozin at least 3 days prior to scheduled surgery (ertugliflozin 4 days).