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Surgery Clearance Form Template

Streamline Your Pre-Surgery Process with This Essential Template

It can be overwhelming to manage clearances before surgery, leaving you worried about compliance and patient safety. This Surgery Clearance Form Template is designed for healthcare professionals like you, ensuring your patients receive timely and organized medical approval for their procedures. With this template, you can easily track patient clearances, streamline communication with medical teams, and enhance compliance with regulations, all while maintaining clear documentation. Start using this practical template today to simplify your surgical clearance process.

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Patient full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary email
Mobile phone
Emergency contact name
Emergency contact phone
Primary care clinician name
Referring surgeon name
Emergency contact relationship
Spouse/Partner
Parent/Guardian
Child
Sibling
Friend
Other
Please Specify:
Planned surgery/procedure
Scheduled surgery date
Surgery facility
Planned anesthesia type
General anesthesia
Regional/Spinal/Epidural
Monitored anesthesia care (MAC)/Sedation
Local anesthesia
Not yet determined
Surgery urgency
Elective
Urgent
Emergency
Can you climb two flights of stairs or walk four blocks without symptoms?
Yes
No
Height
Weight
COVID-19 infection within the past 10 days
Yes
No
Chronic medical conditions (select all that apply)
Other medical conditions (if any)
Prior surgeries and approximate dates
Any prior anesthesia complications
Yes
No
If anesthesia complications, please describe
Personal or family history of malignant hyperthermia
Yes
No
Unknown
Tobacco or nicotine use
Never
Former
Current some days
Current daily
Vaping only
Prefer not to say
Alcohol use
None
Occasional (1-3 drinks/week)
Moderate (4-7 drinks/week)
Heavy (8+ drinks/week)
Prefer not to say
Recreational drug use in the past 30 days
Yes
No
Prefer not to say
Pregnancy status (if applicable)
Not applicable
Pregnant
Not pregnant
Unsure
Prefer not to say
Allergies (select all that apply)
Allergy reaction details
Current medications (include dose and frequency)
Date of last dose of any blood thinner
Blood thinners/anticoagulants
None
Aspirin
Clopidogrel (Plavix)
Warfarin
DOAC (Apixaban/Rivaroxaban/etc.)
Other
Please Specify:
Vital signs (BP, HR, SpO2, Temp)
Recent labs/EKG/imaging summary and dates
Revised Cardiac Risk Index factors (select all that apply)
None
High-risk surgery
Ischemic heart disease
History of heart failure
History of cerebrovascular disease
Diabetes on insulin
Renal insufficiency (Cr > 2.0 mg/dL)
ASA physical status classification
ASA I (Healthy)
ASA II (Mild systemic disease)
ASA III (Severe systemic disease)
ASA IV (Severe disease, constant threat to life)
ASA V (Moribund)
Unknown
Functional capacity estimate
> 10 METs (vigorous)
7-10 METs (moderate-heavy)
4-6 METs (moderate)
< 4 METs (poor)
Unknown
Overall perioperative risk
Low
Intermediate
High
Unable to determine
Surgical clearance decision
Cleared for surgery without restrictions
Cleared with recommendations
Not cleared at this time
Deferred pending additional evaluation
Recommendations, restrictions, or required pre-op optimization
Follow-up plan and referrals
Pre-operative instructions provided to patient
Yes
No
Patient typed signature
Date (patient signature)
Evaluating clinician name
Clinician professional title/credentials
Clinician typed signature
Date (clinician signature)
Clinic contact phone
I acknowledge that I received and understand the pre-operative instructions
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Gender","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a surgery clearance form for an article about FormCreatorAI.

When to use this form

Use this form when a surgeon or anesthesia team needs a standardized risk review before scheduling a procedure. It helps primary care providers, hospitalists, and specialty clinics gather history, meds, allergies, vitals, test results, and sign-off in one place for a medical clearance for surgery form. For example, confirm readiness for outpatient knee arthroscopy, bariatric surgery, or cataract extraction, and document any conditions or holds. If you also need a full exam summary, attach the Medical examination report form. To capture vitals and screening results alongside this form, add the Health screening form. And to streamline return-to-work planning after the procedure, coordinate documentation with the Physician release to return to work form.

Must Ask Surgery Clearance Questions

  1. What is the planned procedure, date, and surgical facility?

    Specifics drive risk assessment, prep timelines, and coordination with the operating room. Clear details reduce back-and-forth and prevent scheduling errors.

  2. What are your current diagnoses and any past anesthesia or surgical complications?

    Chronic conditions and prior events like difficult airway or malignant hyperthermia change perioperative plans. Knowing them early guides testing and consults.

  3. Which medications, supplements, and allergies do you have, including blood thinners and insulin?

    This supports safe hold/start instructions and antibiotic choices. It also flags interactions that may raise bleeding or cardiac risk.

  4. Do you have recent EKG, labs, or imaging, and when were they done?

    Recent results help you avoid duplicate testing and speed sign-off. If gaps exist, you can order what is truly needed.

  5. What is your functional capacity (e.g., can you climb two flights) and your job duties after surgery?

    Functional status (METs) predicts perioperative risk and guides clearance. It also informs duty restrictions you may document alongside the Pre employment physical form.

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