Provider Clearance Form
Fill out this form if you would like to participate in Health & Wellness programming and are of one of the following conditions:
- 45 years of age or older and apparently healthy,
- of any age with health factors of concern (e.g., known heart problems). A health history, physical exam, laboratory tests, x-rays, and/or cardiovascular stress test (CVST) are to be performed at the discretion of my physician in the above situations.
Return by mail, email or fax to (859) 323-4700. For questions, please call (859) 257-9355 (WELL).08/15/2013 (revision date)
Submit paper form to 170 Lancaster Aquatic Center, Lexington, KY 40506-0212
Email form back to firstname.lastname@example.org