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PROCEDURE OF INTEREST


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Preoperative
Surgical Lab/Clearance Request

Millennial Plastic Surgery Logo
212-421-7123

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.

Page Updated on Jun 9, 2023 by Dr. Shokrian (Plastic Surgeon) of Millennial Plastic Surgery