Sample clearance letter for surgery
[DOCX File]Welsh Mountain - Welsh Mountain
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MEDICAL CLEARANCE FOR DENTAL TREATMENT. 5/16/16. Date: Attention: Patient Name: Date of Birth: Our mutual patient, as noted above, is scheduled for dental treatment at our office. Treatment may include: Cleaning (simple or deep) Root Canal Therapy. Radiographs (x-rays) Nitrous Oxide.
[DOC File]865 Return to Duty After Absence for Medical Reasons
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865.1 Certification Required: All Bargaining Unit Employees and Those Nonbargaining Unit Employees Returning From Non-FMLA Absences. Return-to-work clearance may be required for absences due to an illness, injury, outpatient medical procedure (surgical), or hospitalization when management has a reasonable belief, based upon reliable and objective information, that
[DOCX File]Transgender Care
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MEDICAL CLEARANCE LETTER SAMPLE – UCSF TRANSGENDER CARE. PLEASE SEND . ON. OFFICIAL LETTERHEAD. Date: Chosen name:Pronoun:Legal name (if different):DOB:Date established care with referring provider:Procedure sought (separate letter needed for each procedure sought): Date or age at which patient first knew gender ID differed from birth assigned sex:Date began living full time …
SAMPLE DISCHARGE LETTER
letter) while you have an opportunity to arrange for another. physician. Once you have found another physician and we receive. an appropriate authorization, I will forward a copy of your medical. records. I will also be happy to discuss your case with the physician. assuming your care. Enclosed, please find a copy of a medical
[DOC File]SAMPLE LETTER TO SEND TO PATIENTS/Diabetes
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Berkley Clinic. 2905 W. 12 Mile Road. Berkley, MI 48072. T: 248-541-0770. F: 248-541-6862 Compton Clinic. 14325 Middlebelt Road. Livonia, MI 48154. T: 734-427-9222
[DOCX File]Transgender Care
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FTM TOP SURGERY MEDICAL CLEARANCE LETTER SAMPLE. Date . RE:DOB: To Whom It May Concern: Patient name. is a patient in my care at Facility/office name.. He originally established care with us on Date. Patient name has a transmasculine gender identity which is well established and stable. He notes he first knew his gender identity differed from his birth assigned sex at age.
[DOC File]PATIENT ED TEMPLATE.2
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A letter from a primary care provider stating surgical clearance (No need for a Medicine Consult prior to surgery). or A letter from a primary care provider stating medical concerns that must be addressed prior to surgery (see list on following page).
[DOCX File]Audubon Dental Group
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6120 Magazine St. New Orleans, LA 70118-5826. p. 504-891-7471. f. 504-891-8919. Medical Clearance for Dental Treatment. Date:_____ Attn:_____
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