Medical Release Form

This form should be completed by your physician to approve your participation in a personalized training program.

Today's Date *

Training Type

Doctor Information

Doctor Name *

Doctor Phone *

Dear Doctor:

Your patient:

wishes to start a personalized training program. The activity will involve the following:

Activity Description *

TO BE COMPLETED BY DOCTOR

If your patient is taking medications that will affect his or her exercise capacity or heart-rate response to exercise, please indicate the manner of the effect (raises or lowers exercise capacity or heart-rate response):

Type of medication(s):

To be completed by doctor on printed form

Effect(s):

To be completed by doctor on printed form

TO BE COMPLETED BY DOCTOR

Please identify any recommendations or restrictions that are appropriate for your patient in this exercise program:

This section will be completed by the doctor on the printed form.

Thank you.

Sincerely,

Janelle Mistarz

***Add Relevant Certs Here***

TO BE COMPLETED BY DOCTOR

Patient name (for approval):

______________________________________

has my approval to begin an exercise program with the recommendations or restrictions stated above.

Date:

_________________

TO BE COMPLETED BY DOCTOR

Doctor's Signature:

Doctor must sign on printed form

Note: The sections marked "TO BE COMPLETED BY DOCTOR" must be completed by the doctor in person on the printed form.

Cancel

Important: After submitting this form, please print it and have your doctor complete the signature section before beginning your training program.