SAMPLE MEDICAL RELEASE FORM - ACE Fitness

If your patient is taking medications that will affect his or her exercise capacity or heart-rate response to exercise, please.

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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_____________________________________________________________________________