Approved for Surgery
PATIENT NAME
DATE OF BIRTH
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
SURGICAL PROCEDURE
SURGERY APPROVED
Yes
No
REQUIRES SURGICAL CLEARANCE
YES
NO
CLEARANCE LABS/TEST REQUIRED
CBC/ Plt
T&S
PT/ PTT
Glu
Chem 7
LFTs
TFTs
ECG
CXR
U/A
HCG
ALB
Cardio Clearance
Pulmonary Clearance
CLEARANCE PERFORMED
Yes
No
CLEARANCE REPORT
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CLEARANCE SCHEDULED
Yes
No
DATE SCHEDULED
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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