If your patient is taking medications that will affect his or her exercise capacity or heart-rate response to exercise, please.
SAMPLE MEDICAL RELEASE FORM Date ___________________________ Dear Doctor: Your patient, ____________________________________________________________, wishes to start a personalized training program. The activity will involve the following: If your patient is taking medications that will affect his or her exercise capacity or heart-rate response to exercise, please indicate the manner of the effect (raises or lowers exercise capacity or heart-rate response): Type of medication(s)_______________________________________________________________________________________________________________ Effect(s) _______________________________________________________________________________________________________________________________ Please identify any recommendations or restrictions that are appropriate for your patient in this exercise program: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Thank you. Sincerely, ______________________________________________________________________________ has my approval to begin an exercise program with the recommendations or restrictions stated above. Signed___________________________________________________________________________________________________________________________________________ Date____________________________________ Phone_____________________________________________________________________________Adobe InDesign 14.0 (Macintosh) Adobe PDF Library 15.0