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PREOPERATIVE MEDICAL CONSULTATION FORM Please complete and fax to: Ambulatory Surgery 6313512763 and Dr. PATIENT NAME: Date of Birth: Consult Requested of: by Dr. Surgical Date: PST Date: Procedure.

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Your preoperative exam will: Measure your height, weight and vital signs. Review your medication list, with recommendations for how to take your medications prior to surgery. Review your medical, surgical and family history. Include a physical exam.

The Preoperative Checklist is completed by clinicians working within their scope of clinical practice and is designed to aid patient preparation prior to their transfer to theatre and support effective clinical handover when there is a transfer of professional responsibility and accountability.

Your CPT would be outpatient E/M 99201-99215 depending on new/established, and level of care.

Your completed medication history form if you haven't already given this information to a nurse during your pre-surgery consultation. Current reports from medical tests, such as blood work, X-rays or EKG results, if you have them. A list of any medications you take and their dosages. Your health insurance card.

PREOP CLEARANCE LETTER. Please give this to the provider who will be clearing you for surgery. ... 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.

History – documentation of the past medical history, a review of current symptoms, a list of medications, allergies, past surgical history and family history. Physical exam – height, weight, vital signs, and documentation of any abnormal findings on exam of the entire body.

The pre-operative assessment is an opportunity to identify co-morbidities that may lead to patient complications during the anaesthetic, surgical, or post-operative period. Patients scheduled for elective procedures will generally attend a pre-operative assessment 2-4 weeks before the date of their surgery.

What Do I Do Before Surgery? Complete your pre-surgery consultation. ... Avoid tobacco, recreational drugs or alcohol for at least 24 hours before your procedure. Talk to your doctor about how to take your medications before surgery. If you have children, arrange for childcare while you're at the hospital or surgery center.

PREOP CLEARANCE LETTER. Please give this to the provider who will be clearing you for surgery. ... 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.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232