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 clearance letter? Tips For Writing A Tax Clearance Letter Use simple language suitable for the understanding of persons of any class of society. Maintain a good amount of professionalism while writing this letter. Provide all the required information. Mention contact numbers if further queries are required. Mention about all the documents that you have attached with the letter or e-mail.
Author: Tim Perkins
Creator: Microsoft® Word 2010
Producer: GPL Ghostscript 9.27
CreationDate: Mon Aug 19 18:59:48 2019
ModDate: Mon Aug 19 18:59:48 2019
Page size: 612 x 792 pts (letter) (rotated 0 degrees)
File size: 77114 bytes
PDF version: 1.4