Preoperative Clearance Form

Preoperative Clearance Form - Evaluation must be completed within 30 days of the surgery. We are requesting a medical evaluation for surgical clearance. We are requesting a medical evaluation for surgical clearance. The following test(s) are to be obtained prior to the planned surgical procedure:

We are requesting a medical evaluation for surgical clearance. Evaluation must be completed within 30 days of the surgery. The following test(s) are to be obtained prior to the planned surgical procedure: We are requesting a medical evaluation for surgical clearance.

The following test(s) are to be obtained prior to the planned surgical procedure: Evaluation must be completed within 30 days of the surgery. We are requesting a medical evaluation for surgical clearance. We are requesting a medical evaluation for surgical clearance.

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We Are Requesting A Medical Evaluation For Surgical Clearance.

Evaluation must be completed within 30 days of the surgery. The following test(s) are to be obtained prior to the planned surgical procedure: We are requesting a medical evaluation for surgical clearance.

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