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Letter of Medical Clearance For Elective Plastic Surgery
Once you have scheduled your surgery we may ask you to have your primary care physician send us a
letter of medical clearance for surgery. If you have a history of medical illness, are over 55 years old and
or are taking prescription medications for a medical illness we request that you see your primary care
physician and obtain medical clearance to have elective plastic surgery. Most doctors are used to
providing this letter but below are the essential features of the letter we require. You may print the
form below to take to your doctor. All patients over 55 years old are also required to have a recent EKG
or Electrocardiogram to have sent to us before your pre op visit.
This is the information that is required from your Primary Care Physician.
Any tests that have been done at recent office visits should also be included (Lab work, EKG, etc.)
Date of Birth:
History of Present Illness:
Review of Symptoms:
Impression and Plan: I see no contraindications to this patient undergoing elective plastic surgery.
How to write a medical clearance letter for surgery? PREOP CLEARANCE LETTER Please give this to the provider who will be clearing you for surgery I, MD/DO/NP/PA, have examined this patient, checked all appropriate lab work and tests and certify, that to the best of my knowledge, there is not a medical contraindication for undergoing elective surgery with a general and/or regional anesthesia.
Author: Tim Perkins
Creator: Microsoft® Word 2010
Producer: Microsoft® Word 2010
CreationDate: Mon Jan 13 11:28:25 2014
ModDate: Mon Jan 13 11:28:25 2014
Page size: 612 x 792 pts (letter) (rotated 0 degrees)
File size: 307688 bytes
PDF version: 1.4