[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-280901-105":53,"doc-detail-280901-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","surgical-medical-clearance-form-pre-op-evaluation-physician-completion-request","Surgical Medical Clearance Form - Pre-op Evaluation - Physician Completion Request","","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.",{"@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/surgical-medical-clearance-form-pre-op-evaluation-physician-completion-request/280901/",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/surgical-medical-clearance-form-pre-op-evaluation-physician-completion-request/280901.png","ImageObject",442,249,{"name":88,"@type":89},"\tWilliam","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-05","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",23,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who is required to complete the surgical medical clearance form?","Question",{"text":109,"@type":110},"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.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How should the completed form be returned?",{"text":114,"@type":110},"After completion, the form should be faxed to Attention: Patient Care Coordinator at (718)-285-8060, or submitted via email to frontdesk@paramountoms.com.",{"name":116,"@type":107,"acceptedAnswer":117},"What information is collected in the pre-op evaluation section?",{"text":118,"@type":110},"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.","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},280901,1790882999,{"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},5909887254083,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Surgical Medical Clearance Form  \nMedical clearance is needed from your physician before your date of surgery.  \nYour primary care physician should complete the attached form.  \nPlease 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.  \nUpon completion of this form, please fax to:  \nAttention: Patient Care Coordinator  \nFax (718)-285-8060  \n[Email:frontdesk@paramountoms.com](Email:frontdesk@paramountoms.com)  \nIf you have any questions, please contact us via phone at (718)-494-2053 .  \n201 Edward Curry Avenue, Suite 101, Staten Island, New York 10314  \nTel 718-494-2053, Fax 718-285-8060  \nEmail: [frontdesk@paramountoms.com](frontdesk@paramountoms.com)  \n[www.paramountoralsurgery.com](www.paramountoralsurgery.com)  \nDaniel P. Sullivan, DDS - Adam Schuessler, DMD, MD - Avichai Stern, DDS  \nMichael Awadallah, DDS, MD-Shawn Lynn, DDS  \nPre-op Evaluation  \nPatient’s Name  Birth date  / /  Patient’s Phone (HOME)   (MOBILE)   Pre-op Date / /  Surgery Date / /  Diagnosis  Proposed Surgery  Anesthesia  CC:  \nSignificant past medical history:    \n____________________________________________________________________________________  \n____________________________________________________________________________________  \nList of previous operations:    \n____________________________________________________________________________________  \n____________________________________________________________________________________  \nCurrent medication with dosages: Drug and Food Allergies:  \n_______________________________________  \n_______________________________________  \n_______________________________________  \n_______________________________________  \n_______________________________________  \n_______________________________________  \n__________________________________________  \n__________________________________________  \n__________________________________________  \n__________________________________________  \n__________________________________________  \n__________________________________________  \nB/P:  Pulse:   HEENT  LUNGS  CARD/VASC   ABD  EXT  NEURO/PSYCH  DIAGNOSIS  Perioperative Recommendations:   Is this patient cleared to have surgery?   Date:  / /  Print name:   Signature   \n201 Edward Curry Avenue, Suite 101, Staten Island, New York 10314  \nTel 718-494-2053, Fax 718-285-8060  \nEmail: [frontdesk@paramountoms.com](frontdesk@paramountoms.com)  \n[www.paramountoralsurgery.com](www.paramountoralsurgery.com)","cbCaibkpECNAyFjN","https://ap.wps.com/l/cbCaibkpECNAyFjN","pdf",144874,"English","# Pre-op Instructions\n# Pre-op Evaluation Details\n## Medical History and Medications\n## Allergies, Vitals, and System Review\n# Perioperative Recommendations\n## Surgical Clearance Decision","[{\"question\":\"Who is required to complete the surgical medical clearance form?\",\"answer\":\"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.\"},{\"question\":\"How should the completed form be returned?\",\"answer\":\"After completion, the form should be faxed to Attention: Patient Care Coordinator at (718)-285-8060, or submitted via email to frontdesk@paramountoms.com.\"},{\"question\":\"What information is collected in the pre-op evaluation section?\",\"answer\":\"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.\"}]","Surgical Medical Clearance Form - Pre-op Evaluation - Physician Completion Request | PDF",1789561869]