PREOP CLEARANCE LETTER - Arizona Institute for Sports, Knees ...
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:
................
................
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