12040--Pediatric Preparing for Surgery



Battle Building – Check in on 2nd floor                                   Surgical Family Waiting Lounge

1204 West Main Street                                                            1215 Lee Street

Charlottesville, VA  22903                                                      Charlottesville, VA  22908

Surgery Name: ______________________________     Surgery Date:  __________________________

Surgeon Name/Pager: ____________________   ARRIVAL TIME: ______________(provided during phone call)


Thank you for choosing us for your surgery.  We are here to provide you and your family with safe, high-quality healthcare.   Please follow all instructions and be sure all your questions are answered. 


  • A nurse starts making calls (3) days before surgery. Please be sure we know the best phone number to use to contact you.  The nurse gives instructions & arrival time until 6:00pm the day before surgery.
  • Call 434-982-3107 if you have not received a call by noon the day before your surgery - leave a message. 
  • On the day of your surgery, if your child has a cold, cough, fever or flu symptoms, please call OPSC at 434-982-6100.   Staff arrives at 5:30am.  If you get voicemail, leave a message.  Between 6:00pm and 5:30am call 434-924-0000 and ask for the Resident on call for your Surgeon.


  • A nurse will call you between 2:00 and 6:30pm the day before your child’s surgery to give you your arrival time and instructions.  For surgery scheduled for a Monday, you will be called on Friday. 
  • Call 434-924-5455 if you have not received a call by 6:30pm the day before surgery. 
  • On the day of surgery, if your child has a cold, cough, fever or flu symptoms, please call 434-924-0000 ask for the on-call surgeon.
  • If your child is going home the same day, the child’s parent or legal guardian MUST be at the facility during the surgery.  They must be available to receive discharge instructions and give a safe ride home.


If this box is checked:

[]You do not need an anesthesia assessment before surgery.  Follow the instructions on the back page.

If this box is checked:

[]Your child needs to have a WALK-IN Assessment.  Go to PETC (Pre-anesthesia Evaluation and Testing Center)  Hospital Main Lobby, 1215 Lee Street Charlottesville, VA 22908

  • PETC is open Monday-Friday 8am-5:30pm (Wed open 9am)              
  • Bring this handout and any paperwork given to you by your Doctor’s office.   
  • Please allow two (2) hours. Plan ahead - food, drink, ride home, medical equipment, etc. 
  • Your child may have a blood test, test of your heart (EKG), and other tests your surgeon requests. 
  • For questions or if you are unable to visit PETC please call your surgeon.  Failure to visit PETC before surgery may result in cancellation of your child’s surgery.      

If this box is checked:

[] You need to have a PHONE assessment. (Please be sure we know how to reach you.)

    • You do NOT need to go to PETC for your assessment.  It will be done over the phone.
    • A nurse will call you before your surgery to ask you questions about your child’s health.
    • This call should last about 30 minutes.


Please take the time to check off these important points to remember before your surgery.  If, for any reason, you do not plan to come OR your child is sick with a cold, fever, flu symptoms, call your surgeon right away.

  • 2 weeks before surgery my child will stop Vitamins and Supplements (including herbs)
  • 1 week before surgery my child stop Ibuprofen (Motrin®, Advil®, Aleve®, any NSAID)

The NIGHT BEFORE surgery I will help my child: 

  • Remove all makeup and jewelry, including ALL piercings
  • Take usual medicines as instructed, and follow any special instructions given by the surgeon, including taking a shower.  (IF I crush medicines in food, such as applesauce), take the last medicines six (6) hours before “Time to Arrive”
  • NOT eat after midnight

NO FOOD OR BEVERAGES (except clear liquids)AFTER MIDNIGHT; this includes gum and candy.  Your child MAY have only clear liquids until TWO HOURS before your ARRIVAL time:

                    Gatorade, Water, Apple juice, Pedialyte

Children 12 months and younger:

  • May have breast milk until 4 hours prior to arrival time at the OPSC.
  • May have formula until 6 hours prior to arrival time at the OPSC.

I will bring:

  • Any paperwork given to me by my child’s doctor’s office
  • Something to read or do while waiting
  • Comfortable clothes, glasses/contact lens case, and a comfort item for your child

I will not bring:

  • Large sums of money;
  • Valuables such as jewelry or non-medical electronic equipment

For your child’s  safety

  • A parent or legal guardian must be at the facility at all times.  

Please come to -  Lee Street Garage for PETC and Main OR Surgery

                              11th Street Garage for OPSC in the Battle Building

                                                                                           See enclosed map


  • Each time we care for your child we will check the armband and verify identity (name and date of birth).
  • Your child’s Surgical Consent form should be reviewed with you and signed showing your agreement to the surgery; understanding of the need for the surgery; and the risks.
  • We will verify what surgery your child is having and location.  If surgery involves right or left, your physician will mark the site on your child’s body.
  • A time–out check is completed in the OR before surgery to confirm the correct patient, correct procedure and correct location (site).
  • Please feel free to ask all our team members if they washed their hands. We prevent infections by careful hand washing as well as the provision of antibiotics and/or surgical scrub (if needed).                   This information is available at:  https://uvahealth.com/services/surgery