MEDICAL CLEARANCE

MEDICALLY DIRECTED PROGRAMS

MEDICAL CLEARANCE

A BRIEF EXPLANATION

Dear Physician:
The program is specifically designed to address
The facility’s priority is safe exercise for all participants. All participants must complete a comprehensive Pre-Program Assessmenmt Interview, an Informed Consent Waiver, and must have their Primary Physician provide written approval to participate in the form of this Medical Clearance.

FOR YOUR INFORMATION:

CLEARANCE:

Physician – Please INITIAL the appropriate box to indicate your approved clearance for this individual to participate in the medically directed fitness program described above.:
MM slash DD slash YYYY
(Note: When signing digitally, once you type your name it will be saved in a cursive font, and that shall be considered valid and legally binding as if you had physically signed it by hand.)