Get Cardiac Clearance Form

MEDICAL CLEARANCE FORM On the New Member Health Questionnaire you completed you identified that you have one or more coronary or other medical risk factors which may impair your ability to exercise safely. For this reason you need to have a physician complete and return this medical clearance form before you may begin exercising at Presbyterian Hospital s Finley Ewing Cardiovascular and Fitness Center CVC. If the physician is aware of your medical history he/she may be able to complete this form and fax it back to us. I hereby give my permission to release any pertinent medical information from any medical records to the staff at Presbyterian Hospital s Finley Ewing Cardiovascular and Fitness Center. All information will remain confidential. Patient s name print Date Patient s signature Reason for medical clearance Physician s name Phone Address Physician Use Only Please check one of the following statements I approve my patient s participation with no restrictions. We recognize that you are eager to start your fitness program and we sincerely regret any inconvenience that this may cause you. However please keep in mind that we want your exercise experience at the CVC to be as safe as possible. If the physician is aware of your medical history he/she may be able to complete this form and fax it back to us. I hereby give my permission to release any pertinent medical information from any medical records to the staff at Presbyterian Hospital s Finley Ewing Cardiovascular and Fitness Center. All information will remain confidential* Patient s name print Date Patient s signature Reason for medical clearance Physician s name Phone Address Physician Use Only Please check one of the following statements I approve my patient s participation with no restrictions. activities to the program circled below Supervised membership Personal Trainer Arthritis Aquatic/Land MS/Parkinson s Pool Prenatal/Postpartum Pool Exercise Physical Therapy Fitness Assessment Other I do not approve my patient s participation in an exercise program* If checked the individual will not be allowed to join The Finley Ewing Cardiovascular and Fitness Center. Reason I am referring this patient to Pulmonary Rehab Cardiac Rehab Physician s signature Date Please return to Emily Hsueh Business Office Phone 214-345-4659 Fax 214-345-4676. We recognize that you are eager to start your fitness program and we sincerely regret any inconvenience that this may cause you. However please keep in mind that we want your exercise experience at the CVC to be as safe as possible. However please keep in mind that we want your exercise experience at the CVC to be as safe as possible. If the physician is aware of your medical history he/she may be able to complete this form and fax it back to us. If the physician is aware of your medical history he/she may be able to complete this form and fax it back to us. I hereby give my permission to release any pertinent medical information from any medical records to the staff at Presbyterian Hospital s Finley Ewing Cardiovascular and Fitness Center. .