DMAS 351 Revised 3/2012
Surgical Procedure being requested. Reason for the surgery. Include any Pertinent Medical History. Full Vital Signs (Temperature, BP, P, RR, Pulse Oximetry on Room Air) Abnormal Diagnostic Studies: Labs, Imaging, EKG Results. Prior Outpatient Treatment Including Medications Prescribed in Last 72 Hours, Medications and/or IV fluids ordered. ................
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