Primary Physician Medical Clearance Form printable pdf download

Physicians’ Surgical Center

PRIMARY PHYSICIAN MEDICAL CLEARANCE FORM

PATIENT: ________________________________________________ DATE OF BIRTH:___________________________

TYPE OF SURGERY:__________________________________________________________________________________

TYPE OF ANESTHESIA: ( )IV Sedation ( )General Anesthesia ( )Other:

DATE OF SURGERY: _____________________________ BY DR: REICHERT DUGAN WHITTENBURG SNOOK

MEDICAL HISTORY:_____________________________________________________________

_____________________________________________________________________________

SURGICAL HISTORY:_____________________________________________________________

_____________________________________________________________________________

MEDICATIONS & DOSAGES:_______________________________________________________

_____________________________________________________________________________

DRUG ALLERGIES: _________________________________________________________________( ) NKDA

I HEREBY CERTIFY THAT THIS PATIENT IS SUITABLE FOR ELECTIVE SURGERY UNDER IV

SEDATION OR GENERAL ANESTHESIA.

______________________________________ ______________________

PHYSICIAN’S SIGNATURE DATE

________________________________________________________

PHYSICIANS PRINTED NAME

PLEASE RETURN THIS FORM NO LATER THAN 72 HOURS PRIOR TO THE

SCHEDULED SURGERY DATE!

We are recommending the patient to

FAX TO

stop their Coumadin/Plavix for 3 days. If

257‐7049

this is not ok, please recommend

change:

THANK YOU

Associated Foot Surgeons of Belleville

Deborah Heyden, 277‐5700 x 106

Primary Physician Medical Clearance Form