Medical Clearance Form

Downsize Lipo Center of Houston

Dr. Mark Hennessy Suite 780, 7th Floor

Houston, Texas 77030 (832)-955-1221

This patient is scheduled to have liposuction surgery in the near future. Should you choose to see this patient in your office to provide surgical clearance, please ask your office personnel to contact the patient directly, Please Fax your evaluation and any supporting documentation as soon as completed. Thank you, your assistance is greatly appreciated!
Patient's Name*
Patient's Phone: (Cell)*
Please enter a valid phone number.
Patient's Phone: (Home)
Please enter a valid phone number.
Birthdate*

MonthDayYear
Date
Surgery Date

MonthDayYear
Date
Proposed Surgery :
Liposuction
Tumescent
Significant past medical history
List of previous operations
Current Medications with Dosage
Drug Food Allergies
B/P
Pulse
Heent
Lungs
Card/V ASC
EXT
ABD
Neuro/Psych
Diagnoses
Remarks
Is this patient cleared to have surgery
Date

MonthDayYear
Date
Signed

Clear
Should be Empty: