Surgical Clearance Letter
Tanner Foot & Ankle Clinics
Gary N. Oaks DPM
(801)773-4840 ext. 7368 Phone
(801)525-8757 Fax
Patients Name:________________________________________________
Patients DOB (M/D/Y):_________________________________________
Date:___________________________________
The above stated patient has concern(s) of the foot and or ankle and has been requested to seek my recommendations by Dr. Gary N. Oaks regarding their medical stability to tolerate this type of procedure.
I the below signed Doctor/Provider indicate the patient is:
[ ] medically CLEARED for surgery.
[ ] NOT medically cleared for surgery.
[ ] in need of additional test(s) and or other consultation at this time by______________________.
[ ] cleared AS THEIR MEDICAL/SURGICAL SPECIALIST, but the patient also needs to be cleared by PCP.
Comments/Additional Notes: ______________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________ ________________________ _______________
Printed Provider Signature Provider Signature Date (M/D/Y)
__________________________________ ________________________
Provider Address or Stamp below Provider Phone number
___________________________________
Stamp Area
Gary N. Oaks DPM
Tanner Foot & Ankle Clinics
801-773-4865 ext. 7368 Phone
801-525-8757 Fax
Patients DOB (M/D/Y):_________________________________________
Date:___________________________________
The above stated patient has concern(s) of the foot and or ankle and has been requested to seek my recommendations by Dr. Gary N. Oaks regarding their medical stability to tolerate this type of procedure.
I the below signed Doctor/Provider indicate the patient is:
[ ] medically CLEARED for surgery.
[ ] NOT medically cleared for surgery.
[ ] in need of additional test(s) and or other consultation at this time by______________________.
[ ] cleared AS THEIR MEDICAL/SURGICAL SPECIALIST, but the patient also needs to be cleared by PCP.
Comments/Additional Notes: ______________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________ ________________________ _______________
Printed Provider Signature Provider Signature Date (M/D/Y)
__________________________________ ________________________
Provider Address or Stamp below Provider Phone number
___________________________________
Stamp Area
Gary N. Oaks DPM
Tanner Foot & Ankle Clinics
801-773-4865 ext. 7368 Phone
801-525-8757 Fax