HomePre-Operative Medical Assessment Macro Nuvia SD Montefiore Image URL: Referring Doc: Pt Name: DOB: Age: Sex Male Female Procedure: Anesthesia: LA IVS GA Clinic GA OR GA vs LA DOS: Specialist: PCP Cardiology Pulmonology Hematology Oncology/Hematology Labs: CBC CMP Coags HbA1c Tests: EKG Echo Stress Test PFTs Clearance: Yes No Unsure Additional Info: Clinic: Address: City, State: Zip Code: Phone Number: Fax Number: Output Note
