Surgical Clearance
Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgical Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PreOperative Testing For:
Requested
CBC
CMP
UA Reflex Culture
UA Reflex Culture with HCG (if female)
PT INR
A1C
PTT
250 vit D
EKG
Chest X-Ray
Written Medical Clearance & Last Office Note
ALL RESULTS AND WRITTEN MEDICAL CLEARANCE WILL NEED TO BE FAXED TO OUR OFFICES AT 727-873-7408 ATTN: CHERIE C. ASAP!
REQUIRES CARDIAC CLEARANCE
YES
NO
Physician (Electronic Signature)
Please Select
Dr. David T. Braun, MD, MBA
Dr. Andrew D. Boltuch, DO
Dr. Steven Warren, MD
Dr. Jesse Stem, MD
Dx: N39.0, D64.9. I49.9, M12.812, I10, R94.31, R05
Submit
Should be Empty: