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Healthy Lifestyles Fitness Center
55 Augustine Herman Highway
Elkton, MD. 21921
Tel: 410-620-3101
Fax :410-620-3606
Participation in the Healthy Lifestyles Fitness Program requires medical clearance. Please have a physician complete and sign.
Healthy Lifestyles Fitness Center
Physician's Consent Form
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| Participant's Name: |
| Participant's Address: |
| Participant's Telephone Number: |
| Physician's Name: |
Physician's Telephone Number:
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(To be completed by the physician)
In your opinion, is this patient medically cleared to participate in a supervised exercise program?
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| ____ Yes, this patient is medically cleared to participate in a supervised exercise program. |
| ____ No, this patient is not medically cleared to participate in a supervised exercise program. |
Comments or Restrictions:
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Physician's Signature:
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| Date: |
January, 2006
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