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)
Click to view form (pdf or doc): Provider Clearance Form
Submission Options
Submit paper form to 170 Lancaster Aquatic Center, Lexington, KY 40506-0212
Email form back to healthandwellness@email.uky.edu