Medical Clearance Form 2
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Medical Clearance Form
Dear Doctor:
During application for enrollment at the Fitness Center, your patient _____________________________________
completed a Health History and Activity Profile Form. Information on this form indicates your patient will require a
physician’s clearance form. The patient has indicated the following health risk(s):
_________________________________________________________________________________________________
_________________________________________________________________________________________
HealthFit Exercise Specialist/Personal Trainer(print) ______________________________________________
The patient’s exercise program will take place in HealthFit, and will be administered by qualified personnel trained in
conducting exercise programs. If you know of any medical, or other reasons, why participation in the Fitness Center by
the applicant would be unwise, please indicate so on this form. By completing the form below you are not assuming any
responsib