ATLAS FAX CLEARANCE

Atlas Fax Clearance
*** Please inform the patient if an appointment is needed ***
Patient Name
Patient Name
First
Last
Anesthesia Type
Please provide the following results and documentation as soon as possible:
*** PLEASE ATTACH ANY RECENT ECHO OR STRESS TEST WITHIN THE LAST 5 YEARS, IF ANY ***
Provider signing below confirms that patient's condition has been evaluated and is optimized for the above procedure and anesthesia type:
Sign and consent

This is the second form


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