Kevin Blair
 
 
 Kevin Blair DOB: 1989-11-04 (28 yo M) Acc No. 77368 Doc Name: 2015-03-23 Medical Clearance 
 LA Health Solutions 
 3001 Division Street, Ste. 100 Metairie, LA 70002 
 PH (504) 620-5520 FAX (504) 832-3983 
 Please Read Thoroughly 
 I, Kevin Blair understand that if I have any of the following medical 
 conditions listed below, I will need medical clearance for any procedures or 
 surgeries ordered by this office. I further understand that it is my responsibility to 
 provide the name and contact number of my primary care or specialty physician. 
 History of Medical Conditions 
 (Check ALL that apply, If this does not apply, indicate N/A on each line.) 
 NA Heart Attack/Stent/A.Fib/Mitra Valve Prolapse 
 NA High Blood Pressure 
 NA Blood Disorders (Hepatitis/TB/HIV/Anemia) 
 NA Blood Clot/DVT/PE 
 Specialty: 
 Phone: 
 Doctor Name: 
 Specialty: 
 Phone: 
 Doctor Name: 
 Specialty: 
 Phone: 
 I certify that the above information is true and accurate. I authorize the above 
 listed doctor to release all confidential medical records to LA Health Solutions. 
 Print: Signature: 
 Date: 2019-04-11 
 Kevin Blair 
 DOB: 1989-11-04 
 Provider Reviewed: 
 Date: 
 Kevin Blair DOB: 1989-11-04 (28 yo M) Acc No. 77368 Doc Name: 2015-03-23 Medical Clearance 
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