Surgical Medical Clearance Form - Pre-op Evaluation - Physician Completion Request

Sep 16, 2026

Uploaded by William

Surgical medical clearance form for requesting physician approval before a scheduled surgery. The document instructs patients to provide a copy to their primary care physician, complete pre-op evaluation details, and return the completed form via fax or email. It collects patient identity, birth date, contact numbers, pre-op and surgery dates, diagnosis, proposed surgery, anesthesia plan, and key medical history. The form also captures medications, allergies, vitals and system review, perioperative recommendations, and final clearance decision with date, printed name, and signature.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Pre-op Instructions

Pre-op Evaluation Details

Medical History and Medications

Allergies, Vitals, and System Review

Perioperative Recommendations

Surgical Clearance Decision

Surgical Medical Clearance Form Medical clearance is needed from your 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 this form to their office, please direct them to our website at [www.paramountoralsurgery.com](www.paramountoralsurgery.com) and click on Surgical Forms. Upon completion of this form, please fax to: Attention: Patient Care Coordinator Fax (718)-285-8060 [Email:frontdesk@paramountoms.com](Email:frontdesk@paramountoms.com) If you have any questions, please contact us via phone at (718)-494-2053 . 201 Edward Curry Avenue, Suite 101, Staten Island, New York 10314 Tel 718-494-2053, Fax 718-285-8060 Email: [frontdesk@paramountoms.com](frontdesk@paramountoms.com) [www.paramountoralsurgery.com](www.paramountoralsurgery.com) Daniel P. Sullivan, DDS - Adam Schuessler, DMD, MD - Avichai Stern, DDS Michael Awadallah, DDS, MD-Shawn Lynn, DDS Pre-op Evaluation Patient’s Name Birth date / / Patient’s Phone (HOME) (MOBILE) Pre-op Date / / Surgery Date / / Diagnosis Proposed Surgery Anesthesia CC: Significant past medical history: ____________________________________________________________________________________ ____________________________________________________________________________________ List of previous operations: ____________________________________________________________________________________ ____________________________________________________________________________________ Current medication with dosages: Drug and Food Allergies: _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ B/P: Pulse: HEENT LUNGS CARD/VASC ABD EXT NEURO/PSYCH DIAGNOSIS Perioperative Recommendations: Is this patient cleared to have surgery? Date: / / Print name: Signature 201 Edward Curry Avenue, Suite 101, Staten Island, New York 10314 Tel 718-494-2053, Fax 718-285-8060 Email: [frontdesk@paramountoms.com](frontdesk@paramountoms.com) [www.paramountoralsurgery.com](www.paramountoralsurgery.com)

FAQs

Who is required to complete the surgical medical clearance form?

The patient’s primary care physician is asked to complete the attached form after the patient prints a copy and brings it to their office.

How should the completed form be returned?

After completion, the form should be faxed to Attention: Patient Care Coordinator at (718)-285-8060, or submitted via email to frontdesk@paramountoms.com.

What information is collected in the pre-op evaluation section?

It gathers the patient’s name, birth date, phone numbers, pre-op and surgery dates, diagnosis, proposed surgery, anesthesia, significant past medical history, previous operations, current medications and dosages, drug and food allergies, and perioperative recommendations including whether the patient is cleared for surgery.

Sep 16, 2026

Uploaded by William