[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-285831-105":3,"doc-detail-285831-en":81,"detail-sidebar-cat-1-en-105":96},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","beacon-orthopaedics-and-sports-medicine-cardiac-clearance-form","Beacon Orthopaedics and Sports Medicine - Cardiac Clearance Form","","This document is a formal cardiac clearance request form utilized by Beacon Orthopaedics and Sports Medicine to facilitate surgical planning. It requires cardiologists to provide essential patient health data, including recent office visit notes, echocardiograms, EKG results, and stress test findings for patients scheduled for orthopedic surgery. The form incorporates specific protocols for managing common blood-thinning medications, such as Plavix, Aspirin, and Warfarin, alongside comprehensive screening criteria for patients with pacemakers or ICDs. By standardizing the communication between orthopedists and cardiologists, this form ensures the safety of patients undergoing procedures under spinal or general anesthesia at the Beacon Ambulatory Surgery Center or hospital settings. Physicians are requested to evaluate the patient's cardiac stability and determine the appropriate surgical environment, whether outpatient, hospital-based, or delayed pending further diagnostic results.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/beacon-orthopaedics-and-sports-medicine-cardiac-clearance-form/285831/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/beacon-orthopaedics-and-sports-medicine-cardiac-clearance-form/285831.png","ImageObject",442,249,{"name":42,"@type":43},"Berry Peter","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What documentation must the cardiologist provide alongside this form?","Question",{"text":63,"@type":64},"The cardiologist is requested to fax the patient's last office visit notes, as well as any recent test results such as echocardiograms, EKGs, and stress tests.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What are the standard hold periods for common blood-thinning medications?",{"text":68,"@type":64},"The form specifies varying hold times: Plavix, Aspirin, and Brilinta for 7 days; Warfarin for 5 days; Eliquis and Xarelto for 3 days; and Lovenox for 24 hours.",{"name":70,"@type":61,"acceptedAnswer":71},"What is the policy for patients with an ICD scheduled for Total Joint Arthroplasty?",{"text":72,"@type":64},"If a patient is scheduled for Total Joint Arthroplasty and has an ICD, they are not considered a candidate for surgery at the Ambulatory Surgery Center (ASC).","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},285831,1789630367,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":92,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":93,"faqs":94,"seo_title":95,"seo_description":12,"update_tm":80,"read_time":4},1374402524268,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2",17,"Patient Name:   Date ofBirth:   \nProcedure:   Surgeon: Michael Swank   \nDate of Procedure:  TBD  To This Patient’s Cardiologist of Record:  \nI have recently evaluated the above mutual patient for their orthopedic condition. It has been determined that the patient needs a   . The procedure will be performed under spinal/general anesthesia, as an outpatient, at Beacon Orthopedics ASC. We ask that you please fax the patient’s last office visit notes, any recent testing (i.e. echocardiogram, EKG, stress test), and this completed form to fax number listed below.  \nPlease be aware that the patient will need to hold the following medications for the identified period. If you have any concerns regarding the management of these medications, please advise us on their use for this patient:  \n􀀀 Plavix-7 days 􀀀 Aspirin – 7 days 􀀀 Warfarin – 5 days 􀀀 Lovenox – 24 hours 􀀀 Eliquis – 3 days 􀀀 Xarelto – 3 days 􀀀 Brilinta – 7 days  \nDoes the patient have a pacemaker or ICD? Yes No  \n***if patient is scheduled for Total Joint Arthroplasty and has ICD, patient is not a candidate for surgery at ASC. If patient is scheduled for Sports Medicine surgery they may proceed at ASC*** Manufacturer-Model/Serial Number:   Implant Location:   Rep Name and Phone Number:    \nMost Recent Settings: Upper Limit   Lower Limit   Should a magnet be used during surgery? Yes No  \nIs the patient pacemaker dependent? Yes No  \n  Patient may proceed with planned procedure at Beacon Ambulatory Surgery Center, with same day discharge  \n  Patient may proceed with planned procedure in a hospital setting   Delayed cardiac clearance pending test results  \n  Patient is not in satisfactory condition to be cleared for planned procedure  \nPhysician Signature:   Date:   Special Instructions:   \nPlease call Heather with questions @ 513-354-3719 Office Fax: \\# 513-964-9988","cbCailCVgmpEeYyg","https://ap.wps.com/l/cbCailCVgmpEeYyg","pdf",72946,"English","# Patient and Procedure Identification\n## Cardiologist Information and Documentation Requirements\n# Medication Management Protocols\n# Pacemaker and ICD Screening Criteria\n# Surgical Clearance Determination","[{\"question\":\"What documentation must the cardiologist provide alongside this form?\",\"answer\":\"The cardiologist is requested to fax the patient's last office visit notes, as well as any recent test results such as echocardiograms, EKGs, and stress tests.\"},{\"question\":\"What are the standard hold periods for common blood-thinning medications?\",\"answer\":\"The form specifies varying hold times: Plavix, Aspirin, and Brilinta for 7 days; Warfarin for 5 days; Eliquis and Xarelto for 3 days; and Lovenox for 24 hours.\"},{\"question\":\"What is the policy for patients with an ICD scheduled for Total Joint Arthroplasty?\",\"answer\":\"If a patient is scheduled for Total Joint Arthroplasty and has an ICD, they are not considered a candidate for surgery at the Ambulatory Surgery Center (ASC).\"}]","Beacon Orthopaedics and Sports Medicine - Cardiac Clearance Form | PDF",{"code":4,"msg":82,"data":97},[98,102,107,112,117,122,125,130,135],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":99,"show_sort_weight":100,"slug":101},"Presentations",90,"presentations",{"id":103,"doc_module":22,"doc_module_name":25,"category_name":104,"show_sort_weight":105,"slug":106},12,"Resumes",80,"resumes",{"id":108,"doc_module":22,"doc_module_name":25,"category_name":109,"show_sort_weight":110,"slug":111},14,"Invoices",70,"invoices",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},15,"Posters",60,"posters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},16,"Social Media",50,"social-media",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":123,"slug":124},40,"forms",{"id":126,"doc_module":22,"doc_module_name":25,"category_name":127,"show_sort_weight":128,"slug":129},18,"Letters",30,"letters",{"id":131,"doc_module":22,"doc_module_name":25,"category_name":132,"show_sort_weight":133,"slug":134},21,"Paper Templates",5,"papers-templates",{"id":136,"doc_module":22,"doc_module_name":25,"category_name":137,"show_sort_weight":4,"slug":138},158,"General","general-158"]