Surgery Clearance Form
Name
First Name
Last Name
Date of surgery/anesthesia
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgeon recommended patient for medical clearance
Proposed surgical procedure/anesthesia
Indications for medical clearance
Tests/Diagnostics needed
Recommendations for surgery/anesthesia
Comments
The patient is cleared for proposed surgical procedure & anesthesia
Yes
No
Examining Physician
First Name
Last Name
Physician Signature
Submit
Submit
Should be Empty: