Medical clearance forms

July 1, 2011

Medical clearance forms are prepared by the hospital department in order to ensure no –due pending. This is a part of the medical billing form which is the first step for the patients seeking immediate discharge from the hospital.

Sample Medical clearance forms:

Clearance Form Number: ___________________

Date of Preparation: ___/___/___

Name of the concerned doctor: ______________

Specialist details; _________________________

  • Hospital details:

Name of the Hospital: ________________________

Location: _____________________________

Contact Number: ____________________

Billing E-mail id: ________________________

Website: ______________________________

  • Patient Details:

Name: _______________________________

D.O.B: _____________    Sex: _______________

City: __________, State: ___________, ZIP: ______________

Phone Number: _____________________________________

E-mail Address: _____________________________________

  • Clearance details

Current meditations and medicines suggested by the doctor: ___________________

Preferred diagnose on next visit: __________________________________

Details of next visiting & counselling schadule: _____________________________

List if any special precaution is advised to the patient: __________________________

Fitness level of the patient at the time of clearance: ___________________________

Clearance of the billing department: ______________________________________

  • Prepared By: ________________________________
  • Signature of the patient: ______________________
  • Singed by the Doctor: __________________

Download Child Medical clearance forms in Word Format

Sample Search Forms:

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