Medical Release Form
Dear Doctor ________________________:
My Client, ________________________ has hired me as their personal trainer and named you as their primary health care provider. They would like to start a cardiovascular and/or resistance-training program. The program will involve the following:
Type of exercise: ________________________
Intensity level of exercise: ________________________
Please identify any medication that will affect their heart rate and/or blood pressure.
Type of medication: ________________________
Effects of medication: ________________________
Please give any instructions or restrictions pertaining to your client participating in an exercise program.
Clients name: ________________________has been approved to begin an exercise program following the guidelines provided.
Doctor's signature: _______________________ Date: ___________
Phone: ________________________ Fax: _________________________
Your name ___________________________________________________
Contact information _________________________________________