ATLAS FAX CLEARANCE 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
