CARDIAC CLEARANCE REQUEST - Achilles Podiatry
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CARDIAC CLEARANCE REQUEST
Date: _______/_______, 20__ __
Dear Dr. _________________________________________ Cardiologist
Re: Our mutual patient: ____________________________ DOB: ______/_____/_____ The patient is or will be, scheduled for surgery on ___________________, 20__ __ Requiring a MAC or General anesthetic. Length of Procedure: ___________ Hours ___________ Minutes
We are requesting Cardiac Clearance for:
_______ Patient needs the following prior to risk stratification:
________________________________________________________________________ Patient is at low risk for surgery from a cardiac standpoint.
Patient is at increased risk but not prohibitive risk from a cardiac standpoint. To minimize risk, we recommend the following:
3. ____________________________________________________________ Patient is at prohibitive risk from a cardiac standpoint for the above procedure.
Patient May May Not stop Plavix/ASA _________days before procedure. Patient May May Not stop Coumadin _________ days before procedure. Patient may restart Coumadin/Plavix/ASA ____________ days post procedure.
_____________________________________ ( ) _______________-____________
________________________________, 20__ __ Date
PLEASE FAX COMPLETED FORM ASAP TO COMMUNITY SURGERY CENTER NORTHWEST @ (317) 621-3016. ANY QUESTIONS PLEASE CALL (317) 621-3010.
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