Clinical template
Medical Clearance Form
Medical clearance is your name on a risk decision: surgery, sport, or work. Honest options are cleared, cleared with restrictions, or not cleared. A stamp that says 'fit' when you have not examined the patient, or when restrictions exist, is the version that shows up in a college complaint.
Blank clearance letter
Match the heading to the request (pre-op, sport, work). Quote the activity you were asked about. If you did not do the test the requester wanted, say what you did instead rather than ticking a box you cannot defend.
Medical clearance
Date: Clinician / CPSO or college # / clinic: Patient: [name, DOB] | Exam date: Requesting party (surgeon / school / employer / patient): Activity to be cleared (procedure + anesthesia; sport + level; job + physical demands): History reviewed (conditions, meds, allergies, previous clearance/denial): Exam / investigations used for this decision: Decision (pick one) [ ] Cleared for the activity described, without restriction, as of this date [ ] Cleared with restrictions (list restrictions, duration, reassess date) [ ] Not cleared (reason in functional or clinical terms; what would change this) Restrictions / conditions (examples: no contact; no lifting >10 kg; continue CPAP; hold SGLT2; daytime duties only): Duration / review date: I have / have not reviewed the employer's or school's specific form; attached if completed. This is not a guarantee of injury-free participation. It reflects today's assessment for the activity named. Signature:
Fictional patients
Examples are made-up. Clearance is not a medical release (that is consent to send records) and not a sick note with a diagnosis for the employer unless the patient asked for that. Review generated letters before they leave the clinic.
Three common requests
| Type | You are being asked | Usual extra content |
|---|---|---|
| Pre-operative | Whether medical conditions are optimized enough for this surgery and anesthetic | Cardiac/respiratory status, meds to hold (SGLT2, anticoagulants, ACE/ARB per local protocol), CPAP, glucose, who follows post-op |
| Sports / return to play | Whether this athlete can train or compete at a stated level | Injury, concussion protocol stage if relevant, contact vs non-contact, equipment, stepwise return |
| Return to work | Whether this worker can do this job, with or without modified duties | Functional limits (lift, stand, hours, driving, cognitive load), duration, reassess date — diagnosis only if the patient wants it shared |
Employers and schools send their own PDFs. You can complete theirs and still keep a chart note that states restrictions in your words. If the PDF only has 'fit / unfit,' add a sentence or an attachment for restrictions. 'Fit' plus an unwritten 'but no nights' is how the worker gets put on nights anyway.
Example 1 — pre-op, cleared with conditions
Pre-operative medical assessment
69-year-old man, Calgary. Elective TKA. Fictional.
2026-08-26. Dr. N. Grewal, family medicine. Patient: Walter H., DOB 1957-09-03. Exam today. Activity: right total knee arthroplasty, planned spinal anesthetic, Dr. Yee, 2026-09-18. History: HTN, T2DM on metformin + empagliflozin, OSA on CPAP, remote stent 2016, last cardiology 2025 'stable.' Meds confirmed with BPMH. NKDA. Exam / tests: BP 138/82, HR 72, SpO2 96% RA. Chest clear, no edema. ECG NSR, no new ischemic change vs 2025. A1c 7.1% (12 Aug). eGFR 64. Decision: Cleared with restrictions/conditions for the stated procedure as of today. Conditions: bring CPAP to hospital; hold empagliflozin 3 days pre-op (last dose 14 Sep if OR on 18 Sep) because of euglycemic DKA risk; continue metformin unless NPO instructions differ; continue ASA 81 mg unless surgeon/anesthesia instruct otherwise (they have the list). Not a cardiac 'stress test clearance' — no new chest pain, functional class adequate for daily walking; I did not order a further stress test. Anesthesia may still request more. Review: earlier if chest pain, decompensated HF, or A1c unknown at admission.
Example 2 — sport, not cleared yet
Return to play, concussion
16-year-old, hockey, Moncton. Parent present. Fictional.
Activity: return to contact hockey (U18). Injury: concussion 2026-08-18, no loss of consciousness, vomiting day 0, still headache with school screens. Exam: neuro non-focal, balance still off tandem, symptom score not at baseline. Decision: Not cleared for contact or games. Cleared for: stage of return-to-sport protocol — light aerobic only, no resistance that recreates headache, school with breaks. Reassess 2026-09-02 or sooner if symptoms worsen. Parent understands a school form is separate from this sport decision. This letter may be shown to the trainer. No diagnosis detail beyond concussion and current stage unless a release is signed for the club physician.
Example 3 — return to work, restrictions
Modified duties
45-year-old warehouse worker, Windsor. Fictional.
Activity: return to work, employer physical demands — lift 25 kg, standing 8 h, driving reach truck. Problem: mechanical low back strain, 2026-08-12, improving. Decision: Cleared with restrictions from 2026-08-27 to 2026-09-10, then reassess. Restrictions: lift/carry max 10 kg; no repetitive bending; sit-stand as needed; no reach-truck until off opioids (last hydromorphone 20 Aug). Full duties not cleared today. Functional language only on the employer copy. Diagnosis not included unless the worker asks (they did not). Not a WSIB Form 8 — that is a separate form if this is a claim.
What not to do
- Clearing a sport or job you never asked about ('fit for all activities').
- Back-dating clearance to a date before the exam.
- Omitting restrictions to help the patient keep a job — write the restrictions and let them and the employer negotiate.
- Using a medical release signature as if it were clearance.
- Guaranteeing that surgery will be uneventful.
Draft the clearance letter from the visit
Scribeberry can generate a clearance letter in your headings from the exam. You choose cleared, restricted, or not cleared before it is signed. Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What does medical clearance mean?
A clinician's documented opinion that a named person may proceed with a named activity — surgery, sport, or work — with or without restrictions, based on today's assessment. It is not a promise that nothing will go wrong.
Can I clear someone with restrictions?
Yes, and you often should. List the restrictions, how long they last, and when you will reassess. A binary 'fit' box that hides restrictions is worse than a short letter.
Is medical clearance the same as a sick note?
No. A sick note supports absence. Clearance supports participation, sometimes with limits. A medical release is different again: it only authorizes sending records.
Can Scribeberry complete employer or pre-op PDFs?
Scribeberry auto-fills many clinical forms from the visit and drafts letters from templates. You still examine the patient, choose the decision, and sign. Review every restriction line before the form leaves the clinic.
Templates
