O'Grady Orthopaedics



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MEDICAL CLEARANCE REQUEST

(Surgical Pre-Testing)

Date: _April 28, 2017_

To Whom It May Concern:

Please give medical clearance to patient ____________________________ DOB:__________________

The patient will be undergoing _______________________________________________________

with Dr. Christopher O’Grady on____________ under □ general anesthesia □ local anesthesia.

Pre-testing must be done prior surgery, including surgery date

All results must be faxed to us at 850-916-8745 clearly and legible 10 days prior to surgery date.

Required Tests :

• Complete Metabolic Panel

• CBC (with Platelet and Differential)

• PT and PTT

• Urinalysis and Urine Culture (if Indicated)

• Chest X-Ray report only

• EKG (written report stating results in addition to a tracing)

• ***Stress Test only if EKG is abnormal and if you have existing Cardiac Conditions***

• History and Physical with Medical Clearance Letter

If you have any questions please call the office at 850-916-3715.

Thank you,

_______Alan Bowen________

Orthopedic Coordinator

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