Belleville Surgical Center
MEDICAL CLEARANCE FORM
PATIENT: ________________________________________________ DATE OF BIRTH:___________________________
DATE OF SURGERY:_____________________________ BY DR: REICHERT DUGAN WHITTENBURG SNOOK
TYPE OF SURGERY:__________________________________________________________________________________
TYPE OF ANESTHESIA: ( )IV Sedation ( )General Anesthesia ( )Other:
MEDICAL HISTORY:_____________________________________________________________
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SURGICAL HISTORY:_____________________________________________________________
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MEDICATIONS & DOSAGES:_______________________________________________________
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DRUG ALLERGIES: _________________________________________________________________( ) NKDA
I HEREBY CERTIFY THAT THIS PATIENT IS SUITABLE FOR ELECTIVE SURGERY UNDER IV
SEDATION OR GENERAL ANESTHESIA.
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PHYSICIAN’S SIGNATURE
DATE
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PHYSICIANS PRINTED NAME
PLEASE RETURN THIS FORM NO LATER THAN 72 HOURS PRIOR TO THE
SCHEDULED SURGERY DATE!
 We are recommending the patient
FAX TO
stops Coumadin /Plavix /Xarelto 3 days
prior to the surgery date. If this is not ok,
please recommend change:
257-7049
THANK YOU
Associated Foot Surgeons of Belleville
Alice Hurst, 277-5700 x 6