CARDIAC CLEARANCE REQUEST - Achilles Podiatry
[Pages:1]CARDIAC CLEARANCE REQUEST
Date: _______/_______, 20__ __
Dear Dr. _________________________________________ Cardiologist
Re: Our mutual patient: ____________________________ DOB: ______/_____/_____ The patient is or will be, scheduled for surgery on ___________________, 20__ __ Requiring a MAC or General anesthetic. Length of Procedure: ___________ Hours ___________ Minutes
We are requesting Cardiac Clearance for:
Procedure: ________________________________________________________________________
________________________________________________________________________
_______ Patient needs the following prior to risk stratification:
________________________________________________________________________
________________________________________________________________________ Patient is at low risk for surgery from a cardiac standpoint.
Patient is at increased risk but not prohibitive risk from a cardiac standpoint. To minimize risk, we recommend the following:
1. ____________________________________________________________
2. ____________________________________________________________
3. ____________________________________________________________ Patient is at prohibitive risk from a cardiac standpoint for the above procedure.
Patient May May Not stop Plavix/ASA _________days before procedure. Patient May May Not stop Coumadin _________ days before procedure. Patient may restart Coumadin/Plavix/ASA ____________ days post procedure.
_____________________________________ ( ) _______________-____________
Cardiologist Signature
Telephone Number
________________________________, 20__ __ Date
PLEASE FAX COMPLETED FORM ASAP TO COMMUNITY SURGERY CENTER NORTHWEST @ (317) 621-3016. ANY QUESTIONS PLEASE CALL (317) 621-3010.
Revised3/1/13
................
................
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
- eps surgical medical clearance form eye physicians and
- medical clearance for surgery anesthesia
- cardiac clearance request achilles podiatry
- history and physical evaluation form american surgery
- preoperative evaluation acp
- pre surgical medical clearance form
- eps surgical medical clearance form atlanta eye physicians
Related searches
- cardiac clearance calculator
- cardiac clearance icd 10
- icd 10 for podiatry visit
- icd 10 podiatry consult
- podiatry icd 10 codes
- icd 10 podiatry exam
- common podiatry icd 10 codes
- common podiatry codes
- podiatry icd 10 coding book
- cpt codes for podiatry care
- cpt codes for podiatry billing
- cardiac clearance calculator for surgery