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PREOP%CLEARANCE%LETTER%!
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Please!give!this!to!the!provider!who!will!be!clearing!you!for!surgery
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!
!
!
!
I,
MD/DO/NP/PA,!have
!
!
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!
!
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!h a v e!
indicated!those!c lea r ly!in !a !l ett er !to!D r .!B ail ie,!which!accompan ies !th is!
form.!I!have!faxe d!t h e!r eq u ire d !in fo rm a t io n !to !D r.!B a ilie ’s!s ta ff!a t!855-
661-0505!or!emailed!to!surgery@azisks.com!or!given!it!to!the!patient!to!
hand!carry.!
!
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PATIENT!NAME:!!! !!
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PATIENT!DOB:!!! !!
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EXAMINING!PROVIDER!NAME/DEGREE:!!! !!
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EXAMINING!PROVIDER!SIGNATURE/DATE:!!! !!
!!
click to sign
signature
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