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
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