Cardiac clearance request date: / , 20 dear dr. cardiologist re: our mutual patient: dob: / / the patient is or will be, scheduled for surgery on , 20 requiring a mac or general anesthetic. length of procedure: hours minutes we are requesting...
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Saint louis university department of orthopaedic surgery orthopaedic sports medicine patient surgical clearance form scott kaar, md; adnan cutuk, md patient name: today s date: diagnosis: planned surgical date: / / / / planned surgical procedure:...
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Medical clearance form for participation in physical exercise program please print: patient: date: address: telephone:( ) birth date: sex: 1. physical examination: a. b. blood pressure (sitting) ra la c. resting heart rate bpm d. 2. height inches...
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Eps surgical medical clearance form medical clearance is needed from your primary care physician before your date of surgery. your primary care physician should complete the attached form. please print a copy and take to your primary care...
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