[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-280900-105":53,"doc-detail-280900-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","robertson-surgery-clearance-form-pre-operative-medical-evaluation","Robertson Surgery Clearance Form - Pre-Operative Medical Evaluation","","Pre-operative surgery clearance packet for requesting medical evaluation prior to an upcoming surgical procedure. Requires the evaluation to be completed within 30 days of the surgery date and includes patient identification, scheduled procedure details, and provider instructions for completing the full packet. Specifies pre-admission testing responsibilities and required labs (including CBC, Chemistry 10, Coags, Albumin/Transferrin, CRP/ESR, A1c, UA, and Type & Screen), plus potential MRSA screening and EKG/CXR when indicated, followed by a short pre-op H&P section.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/robertson-surgery-clearance-form-pre-operative-medical-evaluation/280900/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/robertson-surgery-clearance-form-pre-operative-medical-evaluation/280900.png","ImageObject",442,249,{"name":88,"@type":89},"Mason","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"How soon must the pre-operative surgery clearance evaluation be completed?","Question",{"text":109,"@type":110},"The evaluation must be completed within 30 days of the surgery date.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information must be provided for the patient and scheduled procedure?",{"text":114,"@type":110},"The packet requires patient name and DOB, plus the surgical procedure scheduled for a specified date.",{"name":116,"@type":107,"acceptedAnswer":117},"Which labs are required for the pre-admission testing?",{"text":118,"@type":110},"Required labs include CBC, Chemistry 10, Coags, Albumin/Transferrin, CRP/ESR, A1c, and UA; Type & Screen is included for the hospital pathway, with additional tests ordered if deemed necessary.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},280900,1790756888,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},5909887256941,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Pre-Operative Surgery Clearance  \n[ ] Primary Care [ ] Cardiology [ ] Neurology [ ] Heme/Onc [ ] Nephrology [ ]    \nWe are requesting a medical evaluation for surgical clearance.  \nEvaluation MUST BE COMPLETED WITHIN 30 DAYS of the surgery date.  \nPatient Name:   DOB:   is scheduled for the following surgical procedure:  \n  on  .  \nPlease complete and fax this entire packet, along with the most recent office visit note and any preoperative testing results, to our office at your earliest convenience. Should this patient require an extensive physical that cannot be completed before the scheduled surgery, or if the patient is NOT cleared for surgery for any reason, please notify our office as soon as possible. I greatly appreciate the opportunity to work with your patients.– Ryan Robertson, MD  \nP: 804-486-6867  \nF: 804-968-1816  \nThis patient is scheduled for surgery at:  \n􀀀 Parham Doctor’s Hospital  \no PCP is responsible for the H&P and any additional labs beyond those listed below  \no Providers may order additional testing if deemed necessary  \no CBC, Chemistry 10, Coags, Albumin/Transferrin, CRP/ESR, A1c, UA, Type & Screen, MRSA Nasal Screening (and EKG/CXR if indicated), will be performed by the hospital at the patient’s pre-admission testing appointment. Labwork that is completed at PAT can be sent to the PCP office at the patient’s request.  \n􀀀 OrthoVirginia Outpatient Surgery Center  \no PCP is responsible for the H&P and all required labs  \no REQUIRED LABS: CBC, Chemistry 10, Coags, Albumin/Transferrin, CRP/ESR, A1c, UA  \no Providers may order additional testing if deemed necessary, but at a minimum PCP must complete the required labs in order for the patient to be eligible for surgery  \no If UA is positive, this should be treated by the PCP  \nSEE NEXT PAGE →  \nPreop H&P Short Form  \nPatient Name:   DOB:   Chief Complaint:   Past Medical History:   History of Present Illness:    \n_________________________________________________________ _____________________  \nMedications/Dosage (as listed below, or attach current medication list) : [ ] anticoagulants/antiplatelets  \n______________________________________________________________________________  \n______________________________________________________________________________  \n____________________________________________________________________________ __  \nAllergies:   Social History: Family History:  \nMarital status (circle one) married / divorced / widowed / single [ ] non contributory Alcohol use [ ] no [ ] yes/frequency:   [ ]    \nDrug use [ ] no [ ] prior [ ] yes; comment:     Tobacco use [ ] no [ ] prior [ ] current/frequency:     Other/comment:     Review of Systems: [ ] 12 system review unremarkable unless otherwise noted  \nExam: Notes:  \nHEENT: [ ] Normal    \nCardiac: [ ] Normal    \nPulmonary: [ ] Normal   Abdominal: [ ] Normal   Extremities: [ ] Normal   Neurological: [ ] Normal    \nImpression & Plan:  􀀀 Patient is medically cleared for surgery  \nSpecific Recommendations:    \n􀀀 Patient is NOT medically cleared for surgery  \nConcerns:    \n_____________________________________________________________________________________  \n________________________ ________ ______________________________  \n(Signature of Provider) (Date) (Printed name of Provider)","cbCaifEIX04Ka08z","https://ap.wps.com/l/cbCaifEIX04Ka08z","pdf",223138,"English","# Pre-Operative Surgery Clearance\n## Evaluation timeline and submission instructions\n## Patient and procedure details\n## Testing and lab requirements by location\n## Preop H&P Short Form\n## Medical clearance outcome and provider signature","[{\"question\":\"How soon must the pre-operative surgery clearance evaluation be completed?\",\"answer\":\"The evaluation must be completed within 30 days of the surgery date.\"},{\"question\":\"What information must be provided for the patient and scheduled procedure?\",\"answer\":\"The packet requires patient name and DOB, plus the surgical procedure scheduled for a specified date.\"},{\"question\":\"Which labs are required for the pre-admission testing?\",\"answer\":\"Required labs include CBC, Chemistry 10, Coags, Albumin/Transferrin, CRP/ESR, A1c, and UA; Type \\u0026 Screen is included for the hospital pathway, with additional tests ordered if deemed necessary.\"}]","Robertson Surgery Clearance Form - Pre-Operative Medical Evaluation | PDF",1789561864]