Eps Clearance Letter Sample Form PDF Details

Getting ready for eye surgery involves more than just setting a date and waiting; it involves ensuring you are physically prepared for the procedure. This preparation includes obtaining a medical clearance from your primary care physician, a critical step mandated by many surgical teams to safeguard your health. The Eps Clearance Letter Sample form is designed for this purpose. It serves as a bridge between your primary care physician and your surgical team, ensuring that all relevant health information is communicated effectively. Patients are asked to print the form and present it to their physician, who will then complete and return it either directly or through provided fax numbers. The form requests details about your medical history, current medications, allergies, and a comprehensive assessment of your present health status, including evaluations of your heart, lungs, and neurological health. Additionally, the form provides space for your doctor to list any previous surgeries and to officially clear you for the upcoming procedure. With easy-to-follow instructions for submission and contact information for further assistance, the form aims to streamline the process, making it as smooth as possible for everyone involved.

QuestionAnswer
Form NameEps Clearance Letter Sample Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessurgical clearance letter template, surgical clearance template, pre op clearance letter, clearance for surgery letter

Form Preview Example

EPS Surgical Medical Clearance Form

Medical clearance is needed from your primary care physician before your

date of surgery.

Your primary care physician should complete the attached form.

Please print a copy and take to your primary care physician’s office for them to complete. We ask that you assist us in ensuring your primary care physician completes this form in a timely manner. If you are unable to take to their office, please direct them to our website at www.atlantaeye.com, and click on Surgical Patient Forms.

Upon completion of the form, please fax to:

Attention: VIP Services

Fax # (404) 294-3353

Alternate Fax # (404) 294-9361

If you have any questions, please contact us via phone at (404) 292-2500.

EYE PHYSICIANS & SURGEONS, PC

Pre-op Evaluation

1457 Scott Blvd Decatur, GA 30030 Phone: 404-292-2500 Fax: 404-267-6709

Charles W. McDowell, Jr, MD

Peter A. Gordon, MD

Paul McManus, MD

John Thomas, MD

Laura Bealer, MD

Indira Menon, MD

Ajeet Dhingra, MD

Christina Weeks, MD

TO DR. __________________________ Voice # _______________ Fax # ________________

__________________________ Voice # _______________ Fax # ________________

This patient is scheduled for eye surgery in the near future. Should you choose to see this patient in your office to provide surgical clearance, please ask your office personnel to contact the patient directly. Please fax your evaluation and any supporting documentation as soon as completed.

Thank you! Your assistance is greatly appreciated!

PATIENT’S NAME____________________________________________________________________

PATIENT’S PHONE (HOME) ___________________ (CELL)_________________________________

x

BIRTHDATE_________________________________PRE-OP DATE___________________________

DIAGNOSIS_________________________________SURGERY DATE_________________________

PROPOSED SURGERY___________________________________ANESTHESIA___________________________

CC:

Significant past medical history:

List of previous operations:

________________________________

___________________________________

________________________________

___________________________________

________________________________

___________________________________

Current Medications with Dosages:

Drug & Food Allergies:

________________________________

___________________________________

________________________________

___________________________________

 

 

B/P:_______Pulse:________

HEENT_____________________________________________________________________________________________

LUNGS_____________________________________________________________________________________________

CARD/VASC________________________________________________________________________________________

ABD_______________________________________________________________________________________________

EXT_______________________________________________________________________________________________

NEURO/PSYCH_____________________________________________________________________________________

DIAGNOSES________________________________________________________________________________________

Remarks:__________________________________________________________________________________________

Is this patient cleared to have surgery? ________________________________________________________________

Date:_______________________ Signed:________________________________________________________, M.D.

Preop eval02/2/11

How to Edit Eps Clearance Letter Sample Form Online for Free

Through the online PDF tool by FormsPal, you can fill out or modify pre op clearance letter here. Our editor is consistently evolving to grant the very best user experience attainable, and that's because of our resolve for continuous improvement and listening closely to user opinions. It just takes a couple of easy steps:

Step 1: Open the PDF inside our tool by pressing the "Get Form Button" at the top of this page.

Step 2: As soon as you open the file editor, you will find the form made ready to be completed. In addition to filling out various blank fields, you might also do various other actions with the PDF, including putting on any textual content, modifying the initial text, inserting illustrations or photos, putting your signature on the form, and a lot more.

This PDF doc will need some specific details; to guarantee accuracy and reliability, you need to take heed of the next steps:

1. The pre op clearance letter will require specific details to be inserted. Make certain the subsequent fields are complete:

surgery clearance letter template conclusion process described (portion 1)

2. Once the last part is finished, it's time to insert the required specifics in EYE PHYSICIANS SURGEONS PC Scott, Preop Evaluation, Charles W McDowell Jr MD Peter A, Preop Evaluation, TO DR Voice Fax, Voice Fax, This patient is scheduled for eye, and PATIENTS NAME PATIENTS PHONE HOME so you can move on further.

Step no. 2 of submitting surgery clearance letter template

3. This third section is quite uncomplicated, List of previous operations, PATIENTS NAME PATIENTS PHONE HOME, and Drug Food Allergies - these form fields needs to be filled out here.

How one can fill in surgery clearance letter template portion 3

4. You're ready to complete this fourth segment! Here you have all these PATIENTS NAME PATIENTS PHONE HOME, and Preop eval fields to complete.

Preop eval, PATIENTS NAME PATIENTS PHONE HOME, and Preop eval inside surgery clearance letter template

People often make some errors while filling out Preop eval in this part. Be certain to revise everything you type in right here.

Step 3: When you have reread the details in the blanks, click on "Done" to complete your form. After starting afree trial account here, it will be possible to download pre op clearance letter or send it through email at once. The PDF form will also be readily available via your personal account with all of your changes. At FormsPal.com, we do everything we can to guarantee that all your details are stored protected.

Eps Clearance Letter Sample Form isn’t the one you’re looking for?

Related Documents