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.