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Surgery Clearance -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Date of surgery/anesthesia

Date
Q4

Surgeon recommended patient for medical clearance
Q5

Proposed surgical procedure/anesthesia
Q6

Indications for medical clearance
Q7

Tests/Diagnostics needed
Q8

Recommendations for surgery/anesthesia
Q9

Comments
Q10

The patient is cleared for proposed surgical procedure & anesthesia
Q11

Examining Physician

First Name
Q12

Examining Physician

Last Name
Q13

Physician Signature