Full systems health and physical and surgical clearance for outpatient dental surgery



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FULL SYSTEMS HEALTH AND PHYSICAL AND SURGICAL CLEARANCE FOR OUTPATIENT DENTAL SURGERY
ATTENTION! PER HOSPITAL REGULATIONS THIS FORM MUST HAVE A DOCTOR’S SIGNATURE.
Today’s Date:___________________ Scheduled Surgery Date: ___________________

Patient Name:______________________________________ DOB:_________________

Height:_______­____ Weight: ________­____ Pulse: ________­____ B/P: ________­____

Respirations:_________________ Temperature:_________________

Diet:______________________ Eyes:_________________ Ears: ___________________

Neck &Thyroid:______________________ Heart & Lungs: _______________________

Abdomen (Palpable organs, masses, etc.): _______________________________________

________________________________________________________________________


Medical History (Please include primary diagnosis, history of major disease, operations and any present medications): ___________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Allergies: ________________________________________________________________

Pre-med required? Yes No If yes, what? __________________________________

Is patient on blood-thinners? Yes No D/C’d when? _________________________
By signing below, I certify that the above patient is cleared for outpatient surgery for necessary dental restorations.

______________________________________________ ________________________

Signature of Physician Only Date and Time
Please print Name: _________________________ Phone: ________________________
Peter A. McIntyre D.D.S., P.C.

Please fax A.S.A.P. to: 719.475.8425



Or e-mail to hospital@mcintyredds.com

Please call Jennifer Labishak, Hospital Program Director with any questions 719.475.2511


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