MEDICAL CLEARANCE CONSULTATION FORM
Adult procedure consultation or work-related assessment
Version 2026-11-11

Use the recipient's required form when applicable. Complete the fields relevant to the proposed procedure or activity.
For employer disclosures, send information appropriate to the request and the recorded disclosure basis.

1. REQUEST FOR ASSESSMENT
Requester: describe the activity and the questions that need a clinical answer.
Patient name / date of birth / encounter identifier:
Page or continuation identifier:
Requester / role / organization / direct contact; request date and version:
Recipient clinician / service; verified reply route; response checkpoint:
Proposed procedure or activity / site; date, setting and urgency:
Anesthesia or sedation plan, or essential job duties and physical demands:
Numbered clinical questions and the decision each answer will inform:
Relevant medical history / recent changes; source and date of each item:
Medicines and actual reported use; allergies and reactions; discrepancies:
Attachments / dates / versions; information still to obtain and owner:
Patient discussion; authorization or other sharing basis; requester authentication:

2. CLINICIAN RESPONSE
Assessing clinician: document findings, recommendations and unresolved questions.
Patient name / date of birth / encounter identifier:
Page or continuation identifier:
Request version and exact procedure / activity / anesthesia scope addressed:
Clinician / role / direct contact; assessment date, time and method:
Relevant history, examination, functional findings and results; sources / dates:
Risk assessment and rationale; tool / inputs / result if used; assessment limits:
Answers to numbered questions; recommendations, restrictions and duration:
Status: recommendation complete / conditions outstanding / further assessment:
Medication plan / prescribing owner / patient instructions issued or still pending:
Open issue / required evidence / responsible person / review checkpoint:
Patient discussion completed; clinician signature / credentials / date / time:

3. RECEIVING-TEAM REVIEW
Receiving team: record the decision, accepted tasks and communication actually completed.
Patient name / date of birth / encounter identifier:
Page or continuation identifier:
Response author / date / version; received by and when; attachments received:
Reviewed by / role / date / time; questions answered or needing clarification:
Resulting procedure or work plan; decision maker / rationale / applicable conditions:
Open task / named owner / acceptance time / checkpoint / overdue-response route:
Medication instructions reconciled; prescribing clinician / communication status:
Patient instructions actually given; by whom / date / route / remaining questions:
Booking or work-arrangement status; changes requiring reassessment:
Record location / verified destination / sent time; reviewer authentication:

Store completed information in the approved record and verify the intended recipient.