MEDICAL RELEASE FORM
Dear Doctor,
Your patient …………………………………………………………. wishes to take part in an exercise programme &/or fitness assessment with Personal Trainer, Carol Winterborne. The exercise programme may include progressive resistance training, flexibility exercises and a cardiovascular programme that will increase in duration and intensity over time. The fitness assessment may include a sub-maximal cardiovascular fitness test and measurement of the body part composition, flexibility and muscular strength endurance.
After completing a readiness questionnaire and discussing their medical conditions we agreed to seek your advice in setting limitations to their programme. Please identify and recommendations or restrictions for your patient’s fitness programme below (see Doctors Recommendations).
Patients Consent and Authorisation
I consent to and authorise Dr …………………………………………………………………. to release to Personal Trainer, Carol Winterborne, health information concerning my ability to participate in an exercise programme &/or fitness assessment. I understand this consent is revocable except to the extent action has been taken. Authorisation is not valid beyond one year from the date of signature. Further disclosure or release of my health information is prohibited without specific written consent of person to whom it pertains.
Client’s signature: ………………………………………………………………………………………………………………………………………………….
Client’s name : (printed) ……………………………………………………………………………………………………………………………………….
Date : ……………………………………………………………………………………………………………………………………………………………………….
Doctors Recommendations
Please check and explain if necessary