MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
CARDIAC CLEARANCE FORM
*Please fill out and fax back to requesting doctor
To:
Our Mutual Patient:
DOB:  
Surgery:
Date Scheduled:
Time:  
Performing Dr.:
Location:
Phone:
Fax:  

Patient takes:
mg
Requested Days Off:
mg
Okay to D/C?
days prior, and restart when advised safe.
Patient Needs to wait until:

Sincerely,
Physician / ANP / RN Signature
Date
Printed Name
Date Faxed
Number of Pages
**Please notify us immediately if you do not receive all pages.
655 Medical Center Dr. NE
Salem, Oregon 97301
503.581.5287
Fax 503.386.1377
mceyeclinic.com