Page 26 - total-hip-packet

Dr. Christian Eccles
Hip and Knee Replacement Surgery
2940 E. Banner Gateway Dr. #200, Gilbert, AZ 85234
1675 E Melrose St, #101, Gilbert, AZ 85297
Phone: 480.964.2908 | Fax: 480.388.3519
Medical Assistant (Reese) extension: 3186
Surgery Scheduler (Debbie) extension: 4141

PRE-OPERATIVE MEDICAL CLEARANCE

Patient’s Name ___________________________________________ Surgery Date: ________________________

Procedure: ☐ Right ☐ Left ☐ Total Hip Arthroplasty ☐ Total Knee Arthroplasty

☐ ________________________________________________________

• Thank you for your help with helping our mutual patient get ready for surgery. Please complete this form

and return it, lab and EKG results, and office note that confirms that the patient is medically optimized for
elective surgery to Fax (480) 388-3519. We request that labs are ordered through your office within 30

days of surgery.

CBC (Hb needs to be at least 12g/dL)
CMP

A1c (needs to be less than 7.5%)

PT/PTT/INR

Pre-operative EKG

☐ ESR/CRP (if it’s a revision)
☐ Serum Cotinine (if recent nicotine history)

• Please also review their current medications and instruct them if there are any that should be held before

surgery (i.e. blood thinners). We recommend stopping NSAIDs for 1 week and herbal supplements for 2
weeks prior to surgery.

☐ Yes, the patient is medically optimized and may proceed with planned surgery

☐ No, the patient should not proceed with the planned surgery at this time

Comments:
_____________________________________________________________________________________________________

Physician’s Name (print) _____________________________________________ Date: __________________________

Physician’s Signature ____________________________________________ Office phone _______________________