Cardiac clearance form 2025

See details

4.9 out of 5

57 votes

The document is a Cardiac Clearance Request form addressed to a cardiologist regarding a mutual patient scheduled for surgery. It outlines the need for cardiac evaluation based on the type of anesthesia required and the length of the procedure. The form includes sections for assessing the patient's cardiac risk, recommendations for managing medications like Plavix, ASA, and Coumadin, and instructions for faxing the completed form to a surgery center.

Here's how it works

01. Edit your cardiac clearance online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send cardiac clearance form via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out cardiac clearance form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the cardiac clearance request in the editor.
Begin by entering the date at the top of the form. This is essential for record-keeping.
Fill in the cardiologist's name and details, ensuring accuracy for effective communication.
Provide the patient's name and date of birth, as this identifies the individual requiring clearance.
Indicate the scheduled surgery date and specify whether it requires MAC or General anesthetic.
Detail the length of the procedure in hours and minutes to assist in risk assessment.
Clearly state any requirements prior to risk stratification, ensuring all necessary information is included.
Select one of the risk categories for the patient’s cardiac status and provide recommendations if applicable.
Indicate whether the patient may stop Plavix/ASA or Coumadin before surgery, along with specific days required.
Finally, ensure that you sign and date the form before submitting it via fax to Community Surgery Center Northwest.

Start using our platform today to streamline your document editing and signing process for free!

See more cardiac clearance form versions

We've got more versions of the cardiac clearance form form. Select the right cardiac clearance form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2013	4.9 Satisfied (57 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to get clearance from a cardiologist?

What to Expect During Your Cardiopulmonary Clearance. During your appointment, your doctor will ask for your medical history and recommend you to undergo a series of tests. Additional medical exams are possible, especially if you have chronic conditions (e.g., hypertension, diabetes, etc.).

When to request cardiac clearance?

If you have a history of heart disease, high blood pressure, or a family history of cardiac issues, this clearance is very important. The additional stress on your heart from the surgery can pose serious risks. With this evaluation, doctors are better equipped for any challenges that might come up.

What does cardiac clearance include?

What to expect during your cardiac preoperative clearance exam Medical history review. We start with a thorough review of your medical history. Physical examination. Next, we perform a detailed physical exam. Electrocardiogram (EKG/ECG) Echocardiogram. Stress testing. Laboratory tests.

Why can cardiac clearance save your life?

Its a thorough evaluation designed to uncover hidden risks, protect you during surgery, and give you the knowledge to manage your heart health going forward. A cardiac clearance appointment isnt just a box to check off. If your surgeon requires cardiac clearance, embrace the process.

How long does it take to get cardiac clearance for surgery?

Typically, the results are available within 24-48 hours. You can then take your results to your surgeon so they can decide how to proceed with your care.

free printable cardiac clearance form

Cardiac Clearance Form for dental procedure Cardiac clearance letter sample Cardiac clearance form for colonoscopy DOT cardiac Clearance Form PDF Cardiac clearance guidelines Surgical Clearance Form pdf Printable Medical Clearance form for surgery Medical clearance form for surgery template

Is cardiac clearance needed for colonoscopy?

Procedures like routine colonoscopies or cataract surgery are often considered low-risk and may not need screenings unless patients have any new cardiac symptoms. I always tell my patients that we just want to make sure they dont have an acute coronary event during or post-surgery, says Dr. Modi.

What is cardiac clearance?

Cardiac clearance typically refers to the process of obtaining approval from a healthcare professional, often a cardiologist, before a person with a known or suspected heart condition can undergo certain medical procedures or engage in specific activities.

Do you need cardiac clearance for a colonoscopy?

Not all surgeries require any preoperative screenings. Procedures like routine colonoscopies or cataract surgery are often considered low-risk and may not need screenings unless patients have any new cardiac symptoms.