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Medical Clearance Form 2


Medical Clearance Form 2
Medical Clearance Form 2
Medical Clearance Form
Dear Doctor:
During application for enrollment at the Fitness Center, your patient _____________________________________
completed a Health History and Activity Profile Form. Information on this form indicates your patient will require a
physician’s clearance form. The patient has indicated the following health risk(s):
_________________________________________________________________________________________________
_________________________________________________________________________________________
HealthFit Exercise Specialist/Personal Trainer(print) ______________________________________________
The patient’s exercise program will take place in HealthFit, and will be administered by qualified personnel trained in
conducting exercise programs. If you know of any medical, or other reasons, why participation in the Fitness Center by
the applicant would be unwise, please indicate so on this form. By completing the form below you are not assuming any
responsibility for your administration of the exercise program.
REPORT OF PHYSICIAN (Please check one)
I know no reason why the applicant may not participate.
I believe the applicant can participate, but I urge caution because: (Please list limitations)
________________________________________________________________________
________________________________________________________________________
The applicant should not engage in the following activities:
________________________________________________________________________
________________________________________________________________________
I recommend that the participant NOT participate.
Information other than what is requested is also greatly appreciated. Thank you in advance for your recommendations and
support of this individual.
_________________________________________________________________________________________________
_________________________________________________________________________________________
Print Physician Name ___________________________________________ Fax# _____________________
Physician’s Signature ___________________________________________ Date _____________________
Address ______________________________________________________ Phone ____________________
City and State _________________________________________________ Zip Code __________________
MEDICAL RECORDS RELEASE AUTHORIZATION
I give permission to release any medical information that may be beneficial for preparing an exercise program to
HealthFit.
Patient Signature ________________________________________________ Date ________________
Patient Name ___________________________________________________
Please return Medical Clearance Form to:
HealthFit: Powered by Sarasota Memorial
5880 Rand Blvd. Suite 102
Sarasota, FL 34238
Phone: (941) 917-7000
FAX: (941) 917-7478
Medical Clearance Form 2