Cardiac Clearance Request Form

Collects a patient's cardiovascular history and details of an upcoming procedure so a physician can assess whether to grant clearance.

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Patient Name

First Name

Last Name

Date of Birth

Email Address

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Reason for Cardiac Clearance Request

Please briefly describe the medical procedure or activity that requires cardiac clearance

Have you ever been diagnosed with any of the following conditions? (Check all that apply)

Hypertension Arrhythmia Heart attack Heart failure Valve disease None

Please provide details for the selected conditions

List any current medications you are taking

Have you experienced any cardiac events in the past? (e.g., heart attack, stroke, angina)

Yes No

If yes, please provide details

Do you have any symptoms of cardiovascular disease? (e.g., chest pain, shortness of breath, dizziness)

Yes No

If yes, please describe the symptoms

Have you previously undergone any cardiac procedures? (e.g., heart surgery, angioplasty)

Yes No

If yes, please provide details

Please provide the contact information of your primary care physician

Please upload any relevant medical reports or documents

Max 10 MB per file

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