PREOP CLEARANCE LETTER - AzISKS
PREOP CLEARANCE LETTER
Please give this to the provider who will be clearing you for surgery
I,
MD/DO/NP/PA, have
examined this patient, checked all appropriate lab work and tests and certify, that to the best of my knowledge, there is not a medical contraindication for undergoing elective surgery with a general and/or regional anesthesia. If special instructions are required, I have indicated those clearly in a letter to Dr. Bailie, which accompanies this form. I have faxed the required information to Dr. Bailie's staff at 855661-0505 or emailed to surgery@ or given it to the patient to hand carry.
PATIENT NAME: PATIENT DOB:
EXAMINING PROVIDER NAME/DEGREE:
EXAMINING PROVIDER SIGNATURE/DATE:
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- sinai hospital of baltimore division of bariatric surgery
- pathway to bariatric surgery checklist trinity medical wny
- 12395 01 bariatric surgery 1 9 4 20 9 20 am
- introduction
- preop clearance letter azisks
- surgical clearance requirements
- sample letter of medical necessity for bariatric
- physican letterhead or medical necessity
- bariatric booklet kaiser permanente
- letter from the primary care physician supporting patient
Related searches
- default clearance letter student loans
- surgical clearance letter template
- preop evaluation forms
- sample clearance letter for surgery
- preop clearance letter
- medical clearance letter pdf
- default clearance letter department education
- default clearance letter form
- pre surgical clearance letter pdf
- preop diagnosis for blepharoplasty
- preop icd and reason for surgery
- clearance letter for surgery template