Request for Surgical Clearance for Bariatric Surgery - Blossom ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields at the top of the form.
3. Review the list of required items for surgery. Ensure that all necessary documents, such as Surgical Clearance, EKG, and Pre-operative Labs, are checked off.
4. Indicate the patient's risk factor by selecting one of the options: Low Risk, Moderate Risk, or High Risk.
5. Add any additional notes or comments in the provided section to clarify any specific concerns regarding the patient’s health.
6. Finally, ensure that you sign and print your name as the physician, along with the date at the bottom of the form before submitting.

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