PHYSICIAN'S CLEARANCE FORM

PATIENT NAME:
DATE:
DEAR DOCTOR

The patient listed above wishes to participate in my exercise program. The program involves the following:

Type of program:
Frequency of program:
Duration of program:
Intensity of program:

Please list any recommendations or restrictions this patient may have with the program described above.

1.
2.
3.

Please list any medications the patient is currently taking which may affect or alter his/her ability to participate in the program.

1.Exercise response
2.Exercise response
3.Exercise response

Thank you for your time.
Sincerely,
Nicole Brewer
Fitness Housecalls
5505 Cassia Drive, Ft. Pierce, Fl 34982
772-708-4553


(patients name) has my approval to participate in the program listed above, with the recommendations and or restrictions as outlined.

Physician's signatureDate:
Address:Phone
   
PHYSICIAN'S CLEARANCE FORM
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