There are 7 forms that need to be completed before we can schedule your CPET appointment:

1.  Physician Referral Form (MUST BE COMPLETED BY YOUR PHYSICIAN)

2.  Cardiovascular Risk Stratification Form 

3.  Authorization for Release of Exercise Test Information (as needed)

4.  Specific Symptom Survey

5.  Canadian Clinical Criteria Questionnaire

6.  Medical History/Health Habit Questionnaire

7.  Informed Consent Document

You can use the links above to download each form separately, or you can access all forms together here. You can type directly into any of the forms using an electronic device or fill them out by hand and re-upload electronic copies. Once you have filled out the forms and have had your physician complete the referral form, please submit through any of the following ways:

E-mail (easiest/fastest): info@workwelleast.org

Fax: (607) 216-1022

Mail: Workwell Foundation East

950 Danby Road, Suite 201-O

Ithaca, NY 14850

The cost for the two-day test protocol and report is $3500. Insurance coverage for this evaluation varies by company, so you should check with your insurer to determine if coverage is available to you.

We do not accept third party payment from an insurance company, Medicare, or Medicaid. Therefore, you are responsible for payment to be made via our secure web portal. We cannot schedule your CPET appointments before health forms and payment are received.

Once all health forms are completed, we will reach out to you directly regarding payment options using the contact information you have provided.

Payment is required in full prior to scheduling the appointment. In the case of a cancellation, there is 15% cancellation fee that is nonrefundable. If traveling by air, travel insurance is highly recommended. 

Once you have 1) submitted your health forms, 2) had your physician send their referral, and 3) completed payment, we will reach out to you again directly using the contact information you have provided. CPET appointments occur over the course of 2 consecutive days, where each appointment is scheduled for the same time on both days. Each appointment is 90 minutes. 

As a reminder, you will only exercise for about 8-12 minutes during each session. It is expected that you schedule your CPETs for a time when you can arrive in a well-rested state, as close to your 'baseline' state as possible. Please plan your travel so you are not overly fatigued upon arrival for your first test. Additionally, someone must drive you to and from the Workwell East Clinic. We cannot test you if you plan to drive yourself from our clinic following a test.

Please review our instructions for a successful CPET and recovery here. More information can be found in the FAQs section of this website.

If you have any questions about testing, please feel free to contact us via e-mail, phone, or the form found under the 'Contact Us' tab!

E-mail: info@workwelleast.org

Phone: (607)-216-3886