Personal Training - Physician's Release Form

Physician's Input Form

Patient Name:
Your patient (listed above) wishes to start a personalized fitness training program. The activity will involve a variety of exercise modalities (i.e. cardio-respiratory, resistive, flexibility, etc.) at various sites including health club, corporate site, home or outdoors. We desire to work with you to assist your patient in meeting his/her health and fitness needs. If your patient is taking medications that will affect his or her response to exercise, please indicate the manner of the effect, (i.e. BP, HR, etc.):

Please identify any recommendations and/or restrictions to your patient's program:

Physicians Name:
Address:
Phone:

This Patient has my approval to begin an exercise program with the recommendations and/or restrictions cited above.