TANNER FOOT & ANKLE CLINICS (801) 773-4865 GARY N. OAKS DPM
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    • Medical Records Release Info
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    • Patient Forms and Policies >
      • New Patient History Form
      • Surgery Instructions and Post Operative Information >
        • Pre Operative Instructions
        • Post Operative Visit Instructions >
          • Ankle stabilization
          • Endoscopic gastrocnemius recession
          • First metatarsophalangeal joint fusion or big toe joint fusion
          • Minimally invasive achiiles tendon repair protocol
        • Assistive Devices
      • Determining Covered Services
      • Disability Form Processing Policy
      • Pain Medications and Controlled Substances
    • Shoe & Orthotic Guide >
      • Shoe Fitting
      • Shoe Stores
      • Lacing techniques
      • Orthotic Break In
    • Rehab and PT after surgery/injury
    • Medical Supplies at Amazon
    • Gait Videos
    • Tanner Clinic Patient Portal
    • Insurances Accepted
    • Patient Survey
    • Terms of use
  • Treatments Provided
    • Common Problems A-J >
      • Ankle Instability
      • Ankle Sprain
      • Arthritis of the Foot and Ankle
      • Blood Clots of the Foot or Leg (DVT)
      • Bone Infections/Osteomylitis
      • Bunion
      • bursitis
      • Callus or Corn
      • Cracked Heels
      • Flat foot
      • Foot Odor
      • Fractured Bones
      • Frostbite
      • Ganglion Cyst
      • Gout
      • Hammertoe
      • Heel Pain
      • Ingrown Toenail
      • Intractable plantar keratosis
      • Joint Pain
    • Common Problems K-Z >
      • Mole/Melanoma
      • Nail Fungus
      • Neuroma
      • Peripheral Artery Disease (PAD)
      • Plantar Wart
      • Puncture Wound
      • Restless Legs
      • Rheumatoid Arthritis
      • Skin Cancer
      • Smelly Feet
      • Stress Fractures
      • Sweaty Feet
      • Swollen Ankle (Edema)
      • Thick Nails
      • Tingling Feet (Neuropathy or Sciatica)
      • Tired Feet
      • Ulcers
    • Diabetic Feet >
      • Amputation Prevention
      • Foot Care
      • Peripheral Neuropathy
      • Diabetic Shoegear
      • Wound Care
    • Kids Feet >
      • Flatfeet
      • Heel Pain in Kids
      • Ingrown Toenails in Kids
      • In toeing, Pigeon toe or Genu Valgum
      • Waddling walk, Duck Walk or Genu Valgum
      • Orthotics
    • Sports Medicine >
      • Achilles Tendonitis
      • Ankle Sprain
      • Athletes Foot
      • Biomechanics
      • Joint Pain
      • Orthotics/Arch Supports
      • Running Injuries
      • Shin Slints
  • About Us
  • Location

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

Tanner Foot & Ankle Clinics

Tanner Clinic-Roy
3443 W. 5600 S. Suite #110
Roy, Utah. 84067
(801)773 4865  Appointment 
​
(801) 525-8757 Fax
DISCLAIMER OF Gary N. Oaks DPM
Gary N. Oaks DPM expressly disclaims all warranties and responsibilities of any kind, whether express or implied, for the accuracy or reliability of the content of any information contained in this Web Site, and for the suitability, results, effectiveness, or fitness for any particular purpose of the services, procedures, advice or treatments referred to herein, such content and suitability, etc., being the sole responsibility of parties other than Gary N. Oaks DPM, and the reliance upon or use of same by you is at your own independent discretion and risk.  For further details see "Terms of Use".
  • Home
  • Make an Appointment
  • Patient Information
    • Medical Records Release Info
    • Office Visit Handouts
    • Patient Forms and Policies >
      • New Patient History Form
      • Surgery Instructions and Post Operative Information >
        • Pre Operative Instructions
        • Post Operative Visit Instructions >
          • Ankle stabilization
          • Endoscopic gastrocnemius recession
          • First metatarsophalangeal joint fusion or big toe joint fusion
          • Minimally invasive achiiles tendon repair protocol
        • Assistive Devices
      • Determining Covered Services
      • Disability Form Processing Policy
      • Pain Medications and Controlled Substances
    • Shoe & Orthotic Guide >
      • Shoe Fitting
      • Shoe Stores
      • Lacing techniques
      • Orthotic Break In
    • Rehab and PT after surgery/injury
    • Medical Supplies at Amazon
    • Gait Videos
    • Tanner Clinic Patient Portal
    • Insurances Accepted
    • Patient Survey
    • Terms of use
  • Treatments Provided
    • Common Problems A-J >
      • Ankle Instability
      • Ankle Sprain
      • Arthritis of the Foot and Ankle
      • Blood Clots of the Foot or Leg (DVT)
      • Bone Infections/Osteomylitis
      • Bunion
      • bursitis
      • Callus or Corn
      • Cracked Heels
      • Flat foot
      • Foot Odor
      • Fractured Bones
      • Frostbite
      • Ganglion Cyst
      • Gout
      • Hammertoe
      • Heel Pain
      • Ingrown Toenail
      • Intractable plantar keratosis
      • Joint Pain
    • Common Problems K-Z >
      • Mole/Melanoma
      • Nail Fungus
      • Neuroma
      • Peripheral Artery Disease (PAD)
      • Plantar Wart
      • Puncture Wound
      • Restless Legs
      • Rheumatoid Arthritis
      • Skin Cancer
      • Smelly Feet
      • Stress Fractures
      • Sweaty Feet
      • Swollen Ankle (Edema)
      • Thick Nails
      • Tingling Feet (Neuropathy or Sciatica)
      • Tired Feet
      • Ulcers
    • Diabetic Feet >
      • Amputation Prevention
      • Foot Care
      • Peripheral Neuropathy
      • Diabetic Shoegear
      • Wound Care
    • Kids Feet >
      • Flatfeet
      • Heel Pain in Kids
      • Ingrown Toenails in Kids
      • In toeing, Pigeon toe or Genu Valgum
      • Waddling walk, Duck Walk or Genu Valgum
      • Orthotics
    • Sports Medicine >
      • Achilles Tendonitis
      • Ankle Sprain
      • Athletes Foot
      • Biomechanics
      • Joint Pain
      • Orthotics/Arch Supports
      • Running Injuries
      • Shin Slints
  • About Us
  • Location