Cardiac Clearance Form

MARCUS A. EAST, M.D.

ADAM T. SHUPE, O.D.

RYAN W. LAPOUR, M.D.

CARDIAC CLEARANCE FORM

*Please fill out and fax back to requesting doctor

To:

Our Mutual Patient:

DOB:

Surgery:

Date Scheduled:

Time:

Performing Dr.:

Location:

Phone:

Fax:

Can proceed from a cardiac standpoint without additional cardiac work up

Patient takes:

ASA mg

Plavix

Coumadin / Pradaxa / Xarelto

Requested Days Off:

ASA mg

Plavix

Coumadin / Pradaxa / Xarelto

Okay to D/C?

YES days prior, and restart when advised safe.

NO Patient Needs to wait until:

Cannot proceed at this time due to:

Sincerely,

Physician / ANP / RN Signature

Date

Printed Name

Date Faxed

Number of Pages

**Please notify us immediately if you do not receive all pages.

655 Medical Center Dr. NE

Salem, Oregon 97301

503.581.5287

Fax 503.386.1377

mceyeclinic.com