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Pre op clearance template

Pre op clearance form pdf 2025

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The document is a preoperative medical evaluation and clearance form for surgery, detailing patient information, medical history, physical examination findings, diagnostic data, and recommendations regarding the patient's fitness for surgery. It includes sections for documenting medical problems, medications, allergies, prior surgeries, and relevant test results. The form concludes with a recommendation section indicating whether the patient is in optimal condition for surgery or if delays are necessary.

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Click ‘Get Form’ to open the pre op clearance form in the editor.
Begin by entering the 'Date of Examination' and selecting whether it must be completed 3 or 7 days before surgery.
Fill in the patient's name, age, sex, date of surgery, and location of surgery at Baptist Hospital.
Provide details about the physician and surgeon involved, along with the proposed surgical procedure and indication for surgery.
Document any medical problems. If there are none, check 'None'. Otherwise, list up to five medical issues.
Indicate cigarette and alcohol use, as well as any medications currently being taken.
Note any allergies or prior surgeries. If none exist, check 'None'.
Complete the physical exam section by filling in vital signs and findings from various body systems.
Attach pertinent diagnostic data results and provide recommendations regarding the patient's medical condition for surgery.
Finally, ensure that a signature is provided along with the MD's name and specialty before submitting.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What does a pre-op clearance consist of?

Pre-op consists of chest and X-rays (to check your lungs), an EKG (to check your heart), and blood tests consisting of a complete blood count (CBC) and liver and kidney blood sugar levels.

How do you write a pre-op clearance note?

PREOP CLEARANCE LETTER. Please give this to the provider who will be clearing you for surgery. examined this patient, checked all appropriate lab work and tests and certify, that to the best of my knowledge, there is not a medical contraindication for undergoing elective surgery with a general and/or regional anesthesia.

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 paperwork do I need before surgery?

Advance Care Directive (Living will) Health Care Proxy (Power of attorney) Durable power of attorney. A synopsis of your medical history and a list of medicines you take or have taken.

What documentation is needed for pre-op clearance?

Your preoperative exam will: Measure your height, weight and vital signs. Review your medication list, with recommendations for how to take your medications prior to surgery. Review your medical, surgical and family history. Include a physical exam.