ATLAS FAX CLEARANCE Atlas Fax Clearance manager@atlasanesthesia.com Office: (312) 883-2564 Fax: (773) 537-4883 *** Please inform the patient if an appointment is needed *** Patient Name Patient Name First First Last Last Date of Birth Phone PCP Phone Fax Procedure Surgeon (s) Procedure Date Procedure Location Procedure Length Anesthesia Type MAC / IV Sedation General Anesthesia Allergies Medications PMH Past Surgical History SMOKE / ETOH Please provide the following results and documentation as soon as possible: Complete History & Physical EKG Echocardiogram Cardiac Risk Assessment CBC CMP HbA1C PT/PTT Lipid Profile Medical Management *** 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: Yes, medically optimized No, is not medically optimized Medications to be STOPPED prior to procedure Sign and consent * I sign the document and hereby authorize ATLAS ANESTHESIA P.C. to use the information. Provider Name and Initials Date Submit If you are human, leave this field blank. This is the second form *** Please inform the patient if an appointment is needed ***manager@atlasanesthesia.comOffice: (312) 883-2564Fax: (773) 537-4883Patient NameDate of BirthPhonePCPPhoneFaxProcedureSurgeon (s)Procedure DateAnesthesia TypeMAC / IV SedationGeneral AnesthesiaAllergiesMedications:PMHPast Surgical HistorySMOKE / ETOHPlease provide the following results and documentation as soon as possible:Complete History & PhysicalEKGEchocardiogramCardiac Risk AssessmentCBCCMPHbA1CPT/PTTLipid ProfileMedical Management*** PLEASE ATTACH ANY RECENT ECHO OR STRESS TEST WITHIN THE LAST 5 YEARS, IF ANY ***Upload fileDrag and Drop (or) Choose FilesProvider signing below confirms that patient's condition has been evaluated and is optimized for the above procedure and anesthesia type:Yes, medically optimizedNo, is not medically optimizedMedications to be STOPPED prior to procedureConsent *I sign the document and hereby authorize ATLAS ANESTHESIA P.C. to use the information.Provider Full Name and InitialsDateSubmit