PREOPERATIVE SURGICAL LAB/CLEARANCE REQUEST

DATE:_______________   TO:__________________

Please perform the following test on patient

(NAME):_____________________________

 

CBC_X___                                                                                 SMA 7_____

PT/PTT____                                                                             CMP__X__

CHEST X-RAY____                                                                  EKG_____

URINE PREGNANCY__X_                                                       UA_____

HbA1c_____                                                                              H&P/MedicalClearance____

OTHER:_____________________________________________________________________

Procedure Date:_____06/10/19______________

 

Diagnosis: Pre-op clearance

Please Fax results to 646-842-9164 or email results to Millennialps@gmail. If there are any questions, please call or text at 646-659-9099 Monday-Friday 9am to 5pm. Thank you for your cooperation and with the assistance in the care of this patient.

Sincerely,

Dr. David Shokrian, M.D.

NY License # 263932-1

UPIN # 1811253081

ALL LABORATORY REQUESTS MUST BE COMPLETED AND RECEIVED BY OUR OFFICE ONE WEEK PRIOR TO SURGERY.