Medical Clearance Form – IL Sports Medicine and Orthopedic Surgery Center

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We have a patient coming to Illinois Sports Medicine and Orthopedic Surgery Center for an upcoming surgery. They have been under your care. We are currently in need of your most recent office notes from their last visit as well as an additional note that states you are comfortable with them moving forward with outpatient surgery.

If you have any questions, please feel free to contact our Contact Nurse at 847-213-5480.

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Patient Name
First Last
Date Of Birth
MM slash DD slash YYYY
Please check the box with regards to proceeding with surgery:
Please make a selection and an appropriate follow up question will appear below.
- This patient is medically cleared for outpatient surgery
- This patient is not medically cleared for surgery due to
- This patient needs to come to see me for an office visit
Reason patient is not medically cleared for surgery:
Please upload pdf of last office note:
Accepted file types: pdf, Max. file size: 24 MB.
if you are unable to upload office notes, please fax to 847-213-5499
Doctors Digital Signature:*
First Last Suffix
Signature Date:*
MM slash DD slash YYYY
Submission Email*
What is the email address of the person submitting the form? A copy of this confirmation will be sent to you.

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