NEPHROLOGY CLEARANCE REQUEST 2026

1. Click ‘Get Form’ to open the NEPHROLOGY CLEARANCE REQUEST in the editor.
2. Begin by entering the date at the top of the form. This is essential for record-keeping and scheduling purposes.
3. Fill in your name as the referring physician, ensuring clarity for communication.
4. Provide details about the patient, including their name and date of birth, which are crucial for identification.
5. Indicate whether the patient is scheduled for surgery and specify the type of anesthetic required by checking the appropriate boxes.
6. Document the length of the procedure in hours and minutes to assist in planning.
7. Clearly state any necessary information regarding nephrology clearance, including risk stratification recommendations.
8. Select one of the risk assessment options provided and list any recommendations if applicable.
9. Sign and date the form at the bottom, ensuring all contact information is accurate for follow-up.
10. Finally, fax the completed form to Community Surgery Center Northwest using the provided number.

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