Medical clearance request form 2025

1. Click ‘Get Form’ to open the medical clearance request form in the editor.
2. Begin by entering the date at the top of the form. This helps track when the request is made.
3. Fill in the surgery date, ensuring it aligns with your scheduling needs.
4. Provide the patient's name and date of birth accurately to avoid any discrepancies.
5. Specify the type of surgery being requested for clearance, detailing any necessary information.
6. Complete the insurance section, including insurance provider details and contact information for verification.
7. List both the ordering physician and surgical coordinator's names along with their contact numbers and fax information.
8. Indicate the hospital or surgery center where the procedure will take place, including their contact details.
9. Check all applicable labs and procedures required for medical clearance from the provided options.
10. Finally, specify any additional medical clearances needed by checking relevant boxes or writing them in.

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