Medical Clearance For Surgery Template

Medical Clearance For Surgery Template – How do you get a surgical clearance? Is medically cleared for surgery. Your physician should complete the attached form. To whom it may concern:

Individuals with a history of dental or gum infections, as these can increase the risk of complications during surgery. The surgical clearance form is essential for patients preparing for surgery. Ekg completed within 180 days of surgery date.

Authorization for medical examination ( . Check for normal exam, indicate abnormal. Z optimized z not optimized z optimized pending .

Prior to your operation, the patient . Your primary care physician should complete the attached form. Is scheduled for the following surgical procedure:

Your patient has been scheduled for foot/ankle surgery. A medical clearance is required by all facilities to . Past medical/surgical history/family history/problem list: .

The surgeon/anesthesiologist is requesting medical/cardiac clearance to determine appropriate management of the patient. Please complete the enclosed medical clearance form and fax or scan the completed h&p and all accompanying documents (blood tests, ekg’s, etc, as . Patient may proceed with planned surgery as scheduled.

Surgeon's Choice Medical Center Surgical Clearance Form