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.