Let Vero draft the letter.
Vero turns your preoperative visit into the risk assessment letter, in your template, with every medicine and its dates spelled out. Check it, then export it to PDF or Word, print it, or send it to the surgeon.
Surgical Clearance Letter Template
A surgical clearance letter gives the surgeon and anesthesia team your assessment of a patient’s medical risk before noncardiac surgery, and what you recommend to lower it. Copy a template built as a risk assessment, not a “cleared” stamp, see a knee replacement and a bowel resection example, and check what the perioperative guidelines say.
- Free, no account needed
- Word and text downloads
- Two filled examples
Blank surgical clearance letter template
FreeSURGICAL CLEARANCE LETTER: PREOPERATIVE RISK ASSESSMENT [Practice name] [Address] [Phone, fax, and secure email] Date: [Date of letter] To: [Surgeon's name and surgical service] Copy to: [Anesthesia or preoperative clinic, and the patient's regular clinician if not you] Re: [Patient's full name] Date of birth: [Date] Seen on: [Date of the preoperative visit] Thank you for asking me to assess [patient name] before surgery. This letter sets out my estimate of medical risk and my recommendations. It is not a guarantee of safety: the decision to proceed, and the anesthetic plan, rest with you and the anesthesia team. PLANNED SURGERY Procedure: [Procedure and side] Date: [Surgery date] Urgency: [Elective, time-sensitive, or urgent] Expected stay: [Same day, or number of nights] Bleeding risk: [Minimal, low to moderate, or high, as the surgical team classes it] RELEVANT CONDITIONS [Each condition, how well controlled it is, and any recent change] Active cardiac conditions: [None found, or what was found] FUNCTIONAL CAPACITY [What the patient does without chest pain or breathlessness, e.g. climbs 2 flights of stairs] Estimate: [4 METs or more, under 4, or unknown; DASI score if used] RISK ESTIMATE Tool and score: [RCRI or another validated tool, with the points counted] Estimated risk: [Risk level, or events per 100 patients, and the outcome it predicts] TESTS Results: [Each test with its date and result, e.g. ECG, NT-proBNP or BNP, A1c, kidney function] Not ordered: [Tests considered, and why they would not change management] MEDICATIONS AROUND SURGERY Continue: [Medicines to take as usual, including on the morning of surgery] Hold: [Each medicine, the date of the last dose, and when to restart] Anticoagulant or antiplatelet: [Plan by drug, kidney function, and bleeding risk; after a coronary stent, the cardiologist's advice] Diabetes medicines: [SGLT2 inhibitor last dose, and any other changes] RECOMMENDATIONS Before surgery: [Anything to treat or adjust first, or none] After surgery: [Monitoring advised, e.g. troponin, and when to call me] [Patient name] knows this estimate and these recommendations. Questions: [Your direct phone or secure email] [Your name, credentials, and specialty] [License or registration number] [Signature]
Use it for
- Joint replacement
- Abdominal and bowel surgery
- Patients on anticoagulants
- Diabetes medicines before surgery
- Requests from preoperative clinics
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Surgical clearance letter: knee replacement, type 2 diabetes on an SGLT2 inhibitor
Family physician to orthopedic surgeon, elective surgery
Planned surgery
Elective right total knee replacement on Thursday, October 29, 2026, with 1 night in hospital. I assessed this 68-year-old man in person on Tuesday, October 13, 2026, at your request.
Conditions
Hypertension, well controlled: 128/78 today, with similar home readings. Type 2 diabetes for 9 years, never on insulin, A1c 7.1%. No known coronary disease, heart failure, stroke, or kidney disease. No chest pain, breathlessness, palpitations, or fainting. Normal heart sounds without a murmur, clear chest, no leg swelling.
Functional capacity
Knee pain limits his walking, but he swims laps for 30 minutes 3 times a week, and climbs a flight of stairs, without chest pain or breathlessness. That is more than 4 METs. Duke Activity Status Index: 36.2, above the cut-off of 34.
Risk estimate
Revised Cardiac Risk Index: 0 points. A knee replacement isn’t one of its high-risk procedures, and he has none of its 5 patient factors. NT-proBNP 112 ng/L, under the 300 ng/L threshold for raised risk. No active cardiac condition. Overall, I estimate his cardiac risk for this operation as low.
Tests
October 13: ECG in sinus rhythm at 68, with no ischemic changes and no change from 2024. NT-proBNP as above. A1c 7.1%; creatinine and potassium normal. I haven’t ordered an echocardiogram or a stress test: he has no symptoms, no murmur, and good capacity, so neither result would change the plan.
Medications
Empagliflozin 10 mg: last dose on Sunday, October 25, and none on October 26, 27, or 28, or on the day of surgery. Restart once he is stable and eating and drinking normally. Ramipril 10 mg: last dose on the morning of Wednesday, October 28, so there is none in the 24 hours before surgery; restart on Saturday, October 31, day 2 after surgery, if his blood pressure is stable. Continue amlodipine 5 mg and atorvastatin 20 mg, including on the morning of surgery. Metformin 1,000 mg twice daily: continue, within the anesthesia team’s fasting instructions.
Recommendations
Nothing to adjust before surgery. With a normal NT-proBNP I haven’t advised routine troponin checks; please check troponin and an ECG if he has chest pain, breathlessness, or a new arrhythmia. Watch his glucose while he is in hospital.
Who decides
He understands this estimate. The decision to proceed, and the anesthetic plan, are yours and the anesthesia team’s. If his health changes before October 29, I will see him again. Signed with credentials and registration number, and sent to the surgeon and the preoperative clinic on Wednesday, October 14, 2026.
Surgical clearance letter: bowel resection, atrial fibrillation on apixaban
General internist to colorectal surgeon, elective surgery
Planned surgery
Elective laparoscopic sigmoid resection for recurrent diverticulitis on Tuesday, October 27, 2026, with 3 to 4 nights in hospital. Your team classes it as high bleeding risk. I assessed this 74-year-old woman on Thursday, October 15, 2026.
Conditions
Permanent atrial fibrillation on apixaban 5 mg twice daily and metoprolol, rate 72 at rest. CHA2DS2-VASc 3, for her age, sex, and hypertension, with no stroke or TIA. Blood pressure 132/80 on amlodipine. No coronary disease or heart failure. An echocardiogram in March 2026 showed normal left ventricular function and no significant valve disease, and nothing has changed since.
Functional capacity
Walks for 30 minutes most days and climbs 2 flights of stairs without stopping, with no chest pain or breathlessness: more than 4 METs. Duke Activity Status Index: 42.7.
Risk estimate
Revised Cardiac Risk Index: 1 point, for intraperitoneal surgery. NT-proBNP 610 ng/L, above the 300 ng/L threshold linked to a higher rate of heart attack or death in the 30 days after surgery. Overall, her cardiac risk is raised. Her capacity is good and she has no symptoms, so I don’t think more testing would change your plan.
Tests
October 15: NT-proBNP as above; creatinine clearance 54 mL/min; hemoglobin normal. ECG: atrial fibrillation at 72, with no ischemic changes and no change from her last tracing. Not ordered: a repeat echocardiogram, as nothing has changed since March, or a stress test, given her good capacity and no symptoms.
Anticoagulation
Apixaban, for a high-bleeding-risk procedure with creatinine clearance above 30 mL/min: last doses on Saturday, October 24, and none on October 25 or 26, or on the day of surgery. No heparin bridging: her clotting risk is low, and bridging adds bleeding. Restart on Friday, October 30, day 3 after surgery, once you are satisfied that bleeding is controlled. If anesthesia plans an epidural or spinal, the guideline advises at least 3 days off a factor Xa inhibitor, which moves her last dose to Friday, October 23.
Other medicines
Continue metoprolol and amlodipine, including on the morning of surgery.
Recommendations
Given the NT-proBNP, check troponin daily for the first 2 to 3 days after surgery, and call me if it rises. Please send me the discharge summary, with the date apixaban restarted.
Who decides
She knows her risk is raised and wants to go ahead. Whether and when to operate is your decision, with the anesthesia team. Signed with credentials and registration number, and copied to the preoperative clinic and her family physician on Friday, October 16, 2026.
What the perioperative guidelines say. Checked October 2026.
The US and Canadian cardiology guidelines agree on the shape of the assessment, but differ on risk tools, functional capacity, biomarkers, troponin, and some medicines. Follow the one your surgical team works to, and the hospital’s own policy.
United States, risk and testing
For patients with known cardiovascular disease, a validated risk tool can be useful (Class 2a); elevated risk generally means a 1% or higher risk of a major cardiac event. Before elevated-risk surgery, a structured functional capacity assessment such as the DASI is reasonable (2a); poor capacity is under 4 METs or a DASI of 34 or less. Stress testing may be considered for elevated-risk patients with poor or unknown capacity (2b). Routine stress testing in low-risk patients or those with adequate capacity, and routine assessment of heart function in stable patients without symptoms, are not recommended.
Canada, risk and testing
Applies to patients 45 or older, or 18 to 44 with known significant cardiovascular disease, having surgery with at least an overnight stay. Suggests the RCRI over other risk scores, and recommends giving the risk as expected events per 100 patients. Recommends against resting echocardiography, CT coronary angiography, exercise or cardiopulmonary exercise testing, and pharmacological stress imaging to estimate risk. Makes no recommendation on self-reported functional capacity.
United States, BNP and troponin
For patients with known cardiovascular disease, aged 65 or older, or 45 or older with symptoms suggesting it, having elevated-risk surgery, measuring BNP or NT-proBNP before surgery is reasonable (2a), and a preoperative troponin may be reasonable (2b). Abnormal is NT-proBNP of 300 ng/L or more, or BNP above 92 ng/L. Troponin at 24 and 48 hours after elevated-risk surgery may be reasonable for patients with cardiovascular disease or its symptoms, or 65 or older with risk factors (2b). After low-risk surgery, routine troponin screening isn’t indicated without signs or symptoms of ischemia.
Canada, BNP and troponin
Recommends measuring NT-proBNP or BNP before surgery in patients 65 or older, 45 to 64 with significant cardiovascular disease, or with an RCRI score of 1 or more; an NT-proBNP of 300 ng/L or more marks a higher risk. Recommends daily troponin for 48 to 72 hours after surgery when NT-proBNP or BNP is raised or, if it wasn’t measured, in the same groups.
United States, medicines
Stop SGLT2 inhibitors 3 to 4 days before surgery: canagliflozin, dapagliflozin, and empagliflozin at least 3 days, ertugliflozin at least 4 (Class 1). Continue stable beta-blockers and statins (1), and don’t start a beta-blocker on the day of surgery. In selected patients with controlled hypertension, omitting a RAAS inhibitor for 24 hours before elevated-risk surgery may limit low blood pressure during surgery (2b). Interrupt oral anticoagulants on a time-based schedule agreed by the team, by drug, kidney function, and bleeding risk, without routine bridging. Elective surgery that interrupts antiplatelets should ideally wait at least 12 months after a drug-eluting stent for acute coronary syndrome; after one for chronic coronary disease, waiting at least 6 months is reasonable.
Canada, medicines
Continue beta-blockers, considering a lower dose or holding it if systolic pressure is low, and continue statins. Withhold ACE inhibitors and ARBs from 24 hours before surgery, and restart them on day 2 if the patient is hemodynamically stable. Withhold ASA at least 3 days before surgery, except after a recent coronary stent or for carotid endarterectomy, and restart it 8 to 10 days after major surgery when there is an ongoing indication. Don’t start a beta-blocker within 24 hours before surgery. The guideline doesn’t cover SGLT2 inhibitors or anticoagulants.
Canada, physicians’ risk assessments
The CMPA notes that “medical clearance” is generally no longer used: it has no standard definition, and every procedure carries risk. It advises basing the assessment on what you know of the patient and staying within your expertise, being open about its limits, using language that recognizes the risks of any treatment, and, where you judge the risk low enough, framing your opinion by the probable risk level.
United States, hospitals
Under the Medicare hospital Conditions of Participation, a history and physical must be done no more than 30 days before or 24 hours after admission or registration, and before surgery or a procedure needing anesthesia. If it was done in the 30 days before, an update noting any change in the patient’s condition must be documented within 24 hours after admission or registration, and before surgery. Medical staff may adopt a policy allowing a narrower assessment for specified outpatient procedures.
What goes in each part.
Planned surgery
The procedure decides much of the risk, so start with what is planned and how soon.
- The procedure, side, and date
- Elective, time-sensitive, urgent, or emergency
- Same-day or inpatient, and the expected stay
- The bleeding risk, as the surgical team classes it
Avoid: Assessing a patient for “surgery” without knowing which one. A cataract operation and a bowel resection carry very different risks.
Conditions and functional capacity
The conditions that bear on surgical risk, how well each is controlled, and what the patient can do without symptoms.
- Heart, lung, kidney, and metabolic conditions, with recent readings such as blood pressure and A1c
- Any unstable or severe cardiac condition: unstable angina, decompensated heart failure, a significant arrhythmia, severe valve disease, or severe pulmonary hypertension
- Activity without chest pain or breathlessness; climbing 2 flights of stairs is more than 4 METs
- A Duke Activity Status Index score if you use it: 34 or less counts as poor capacity
Avoid: “Good exercise tolerance” with no detail. Write what the patient actually does.
Risk estimate
Your estimate of the risk, from a validated tool and your assessment, in place of the word “cleared.”
- The tool and the score, such as the Revised Cardiac Risk Index, with the points counted
- The estimate, as a risk level or as events per 100 patients, and the outcome it predicts
- Biomarker results that change the estimate, if you measured them
- What, if anything, would lower the risk
Avoid: “Low risk” with no basis. Tools give different numbers for the same patient, so name the one you used.
Tests
What you checked, and why you didn’t order more. Current guidelines advise against routine heart scans and stress tests in stable patients.
- Each result with its date: ECG, NT-proBNP or BNP, A1c, kidney function, hemoglobin
- The tests you considered and left out, and why
- Any test still pending, and who will act on the result
Avoid: Ordering an echocardiogram or stress test by routine. Test only when the result would change the plan.
Medications around surgery
Drug by drug, with the date of the last dose and when to restart, so the patient and the ward can follow it.
- SGLT2 inhibitors: stop at least 3 days before surgery, ertugliflozin at least 4, and restart once the patient is stable and eating normally
- Anticoagulants: a schedule set by the drug, kidney function, and the bleeding risk, with no routine bridging
- Antiplatelets after a coronary stent: the cardiologist’s advice, never a stop on your own
- Beta-blockers and statins: continue; don’t start a beta-blocker on the day of surgery
- GLP-1 receptor agonists: the anesthesia team’s instructions, as the evidence is still limited
Avoid: “Hold blood thinners for a week.” Name each drug, its last dose, and its restart.
Recommendations and who decides
What you advise before and after surgery, and a plain statement that the decision to operate isn’t yours.
- Anything to treat or adjust first, and whether it means waiting
- Monitoring after surgery, such as troponin checks for higher-risk patients
- That the patient knows the estimate
- That the surgeon and anesthesia team decide whether and when to proceed
- How to reach you with questions
Avoid: “Cleared for surgery.” Every procedure carries risk, and the letter can’t promise otherwise.
Common mistakes, and how to avoid them.
“Cleared for surgery” and nothing else
A one-line clearance tells the surgeon nothing they can use, and promises a safety no one can give. State the risk, how you estimated it, and what you recommend.
Tests that won’t change the plan
A stable patient with good functional capacity rarely needs an echocardiogram or a stress test before surgery. Each one can delay the operation without lowering the risk.
Stopping antiplatelets after a stent
Interrupting antiplatelet therapy soon after a coronary stent risks stent thrombosis. Agree any change, and the timing of surgery, with the cardiologist.
Vague medicine instructions
“Hold diabetes pills” or “stop blood thinners” leaves the patient guessing. Give each drug, the date of its last dose, and when it restarts.
A letter that has gone stale
Your estimate holds for the patient you saw. If symptoms change or the surgery is postponed, ask to see them again before the new date.
Try Vero free
Frequently asked questions.
What should a surgical clearance letter include?
The planned surgery, its date and urgency; the patient’s relevant conditions and how well they are controlled; functional capacity; a risk estimate from a validated tool; test results, and why you didn’t order others; which medicines to continue or hold, with dates; your recommendations; and that the surgeon and anesthesia team decide whether to proceed.
Should I write “cleared for surgery”?
It’s better not to. “Clearance” has no standard meaning, and every procedure carries some risk. Give your estimate of the risk and how you reached it, and leave the decision to operate with the surgeon and anesthesia team.
Who decides whether the surgery goes ahead?
The surgeon and the anesthesia team, with the patient. Your letter informs that decision: it estimates the medical risk and recommends ways to lower it.
Does every patient need an ECG, echocardiogram, or stress test before surgery?
No. Current guidelines advise against routine echocardiograms in stable patients without symptoms, against routine stress tests in patients at low risk or with good functional capacity, and against routine ECGs before low-risk procedures. Order a test when its result would change the plan. The guidelines differ on BNP and troponin, so check the one your surgical team follows.
How do I assess functional capacity before surgery?
Ask what the patient can do without chest pain or breathlessness. Climbing 2 flights of stairs is more than 4 METs, and under 4 METs counts as poor capacity. The Duke Activity Status Index gives a score from 12 questions, and 34 or less counts as poor.
When should SGLT2 inhibitors be stopped before surgery?
At least 3 days before for canagliflozin, dapagliflozin, and empagliflozin, and at least 4 days for ertugliflozin, to lower the risk of ketoacidosis. Restart once the patient is stable and eating normally.
Show all questions
How long before surgery should a patient stop apixaban or rivaroxaban?
It depends on the bleeding risk of the procedure and kidney function. Under a widely used schedule, with creatinine clearance of 30 mL/min or more, the last dose is 2 days before a low-to-moderate bleeding risk procedure and 3 days before a high-risk one, with no bridging. Spinal or epidural anesthesia may need longer, so agree the plan with the surgical and anesthesia teams.
How long is a surgical clearance letter valid?
There’s no single expiry. Hospitals often require a history and physical within a set time before surgery, and an update on admission. If the patient’s health changes or the surgery is postponed, reassess.
Is this surgical clearance letter template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
Can Vero write a surgical clearance letter from my visit?
Yes. Paste this template into Vero, and it drafts the letter from your preoperative visit, with the risk estimate, the tests, and each medicine’s dates. Review and edit it, then export it to PDF or Word, print it, or send it.
More templates, and guides.
Doctor’s note template
For work or school: the visit, the dates off, the return, and any limits.
Return-to-work note template
To an employer: full or modified duties, the restrictions, how long they last, and the review date.
Medical leave letter template
To an employer or leave administrator: when the leave starts, how long it lasts, the review date, and what the return needs.
Workplace accommodation letter template
To an employer: what the condition limits, the change that would help, how long, and answers to the employer’s questions.
Pregnancy accommodation letter template
To an employer: the pregnancy-related limitation, the change needed at work, and how long it lasts.
Consultation letter template
The specialist’s reply to a referral, with who does each next step.
Referral letter template
Ask a cardiologist or other specialist to see the patient before surgery.
Referral management
Handoffs between clinicians, and letters drafted from the visit.
Vero Documents
Fill a hospital’s preoperative forms from the visit and the chart.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
Try Vero free
No credit card required. 10 free actions every month.