MEDICAL RELEASE FORM Step 1 of 2 50% Section I: Medical Information Release, (To be completed by fitness professional)Dear Physician: Your patient, _______________________________, has expressed interest in participating in a personalized exercise program. The program will involve the following: Time/Duration of Cardiovascular MM slash DD slash YYYY Intensity of Cardiovascular Time/Duration of Resistance Training MM slash DD slash YYYY Intensity of Resistance Training Time/Duration of Flexibility MM slash DD slash YYYY Intensity of Flexibility Other Time/Duration of others MM slash DD slash YYYY Intensity of others Additional Notes from Fitness Professional Section II: Physician Approval (To be completed by participant’s physician)If your patient is taking medications that will affect his/her heart rate response to exercise, please indicate the manner of the effect (raises, lowers, or has no effect on heart rate response):Please indicate patient recommendations or restrictions regarding this exercise program:has my approval to begin an exercise program with the recommendations or restrictions stated above.Physician SignatureDate MM slash DD slash YYYY Please Print Name First PhoneI hereby give my physician permission to release any pertinent medical information from my medical records to _________________. I understand that this information will be kept confidential. Participant SignatureDate MM slash DD slash YYYY Δ
