pre op dental clearance form

Get the free pre op dental clearance form

Saint Louis University Department of Orthopaedic Surgery Orthopaedic Sports Medicine Patient Surgical Clearance Form Scott Kaar MD Adnan Cutuk MD Patient Name Today s Date Diagnosis Planned Surgical Date / Please fax recent CMP CBC PT INR PTT UA CXR EKG Patient is medically cleared for surgery on Peri-operative comments/recommendations Clearing Physician s Name Signature Please fax this form to 314 268-5121 and any other relevant documentation to...
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If you fax with fax settings turned on, please send this to:. Your fax number should then appear on your invoice as Scott. If you cannot see your fax number on your invoice, please check your spam folder. Please fax this to. If you fax with fax settings turned on, please send this to:. Your fax number should then appear on your invoice as Scott. If you cannot see your fax number on your invoice, please check your spam folder. Your Patient Surgical Clearance Form must be signed and notarized. Must be signed and notarized. A notarized copy of your current medical license (if any) or current government issued identification card (if any) or any other identification, such as a passport, should be faxed with the above form to. All documents must be in English. If English is not your first language, it is recommended that an interpreter be present. Please fax this to. All documents must be in English. If English is not your first language, it is recommended that an interpreter be present. Your patient ID number (if it's not in the above list) must be included in the faxed copy and also on the original form. In addition to faxing the original, please also fax a copy of, and a signed, copy of the current Medicare/Medicaid Claim Form that you have with you, or that you will upload onto the website at the conclusion of your appointment. If you have an older claim form, please fax a copy of the completed “Medicare/Medicaid Discharge Petition/Medicare Claim Form” on your current Medicare/Medicaid form, or on a notarized, copy of the current Medicare/Medicaid form which was completed for you when you enrolled. If a faxed copy of the Medicare/Medicaid Claim form does not appear to be sufficient, please download and download the patient form which will be available on this website on the day of your surgery. Please be sure to include the patient ID number as requested above.
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