Your Name * Required First Last Surgeon's Name * RequiredSelect Surgeon NameAndreoBozicCarterDavisDriscollGallagherGrahamHussainiHillKoenigManuelPadaleckiParkerSchramSchultzSeaquistSullivanSzerlipOtherIs your surgery scheduled? * RequiredYesNoIf your surgery is scheduled, please select the date. - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Type of Surgery * RequiredSelect Type of SurgeryTotal hip replacementTotal knee replacementBilateral hip replacementsBilateral knee replacementsUni-compartmental knee replacementRevision total hipRevision total kneeQuestion 1: Discharge planning starts before surgery. Plan ahead for someone to be available to help you the first few days after you go home. * RequiredTrueFalseQuestion 2: The "Care Guide" outlines what you can expect daily while in the hospital including your ambulation (walking) and pain management goals. This is located in your pre-op booklet and also will be hanging on the wall in your hospital room. * RequiredTrueFalseQuestion 3: The Case Manager will order your walker and make the referral to a Home Health Agency for Physical Therapy home visits. * RequiredTrueFalseQuestion 4: Your nurse will review and give you discharge instructions before going home. Make sure you ask questions, clarify, and understand how to continue your care at home. * RequiredTrueFalseQuestion 5: You will continue to take blood thinner medication for at least 4 weeks or as directed by your surgeon to prevent getting a blood clot on your leg. * RequiredTrueFalseEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.