Medical Clearance Form - Houma Outpatient Surgery Center
Houma Outpatient Surgery Center, AAAHC ACCREDITED
3717 Houma Blvd, 3rd Floor P: 504 456 1515
Metairie, La. 70006
F: 504 454 3810
Houma Outpatient
Medical Clearance for Surgery/Anesthesia
Patient:
Date of Surgery/Anesthesia:
Surgeon recommending patient for medical clearance: Proposed surgical procedure & anesthesia:
Indications for Medical Clearance:
Labs/Tests/Diagnostics needed:
Patient is cleared for proposed surgical procedure & anesthesia
Yes
No
Recommendations for surgery/anesthesia:
Comments:
Examining Physician: (please print)
Signature
Date/Time
Please return this form and any accompanying documentation to HOSC as soon as possible
Houma Outpatient Surgery Center is a physician-owned, ambulatory surgery center that provides quality care for the New Orleans area.
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