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Surgical medical clearance form 2026

The EPS Surgical Medical Clearance Form is a document that requires patients to obtain medical clearance from their primary care physician before undergoing eye surgery. Patients must print the form and take it to their physician, or direct them to the website for completion. The completed form should be faxed to VIP Services at specified numbers. The document includes sections for patient information, medical history, and a declaration of surgical clearance by the physician.

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Click ‘Get Form’ to open the surgical medical clearance form in the editor.
Begin by entering the patient's name, phone number, and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the pre-op date and surgery date. This helps your primary care physician understand the timeline for clearance.
Provide details about the proposed surgery and anesthesia type. This section informs the physician about what they are clearing the patient for.
Document any significant past medical history and previous operations. This information is vital for assessing the patient's overall health.
List any drug allergies and current medications, including dosages, to ensure safe surgical practices.
Complete the vital signs section (blood pressure, pulse) and any relevant physical examination findings.
Finally, indicate whether the patient is cleared for surgery by checking 'YES' or 'NO', then have your physician sign and date the form before submission.

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What do you need for a medical clearance?

The medical clearance is based upon the employee participating in a complete head-to-toe physical examination, a complete blood panel, a health history questionnaire, an EKG, vision test, pulmonary function test, hearing test, and a stress test for those over the age of 40 or at the discretion of the provider.

What is required for medical clearance?

A medical clearance usually consists of a doctor visit where your medical history is reviewed, a physical exam, and any needed testing is ordered. If you are cleared healthy enough to participate in the activity you desire, the doctor will provide the medical clearance necessary to move forward.

What is a medical clearance for surgery paperwork?

A surgical clearance form is used to determine a patients eligibility for surgery. It is used to assess the patients overall medical condition, to document any existing medical conditions that may affect the outcome of the surgery, and to verify that the patient is healthy enough for the procedure.

Where can I get a clearance letter for surgery?

Answer: Primary physician Your surgeon should be able to give you a referral for a primary doctor you can see for medical clearance. Another option is to contact your insurance carrier for primary care physicians in your area who are accepting new patients.

What is a medical clearance letter from a doctor?

The term is often used by surgeons requesting a medical evaluation before performing surgery on a patient. In the context of surgery, a medical clearance is, essentially, considered to be an authorization from an evaluating clinician that a patient is cleared, or deemed healthy enough, for a proposed surgery.