Physician’s Release Form

Date

Patient Name

First

Last

Patient Address

City

State

Zip

Patient Email

Name of Health & Wellness Program the Patient will be joining.

Physician’s Office/Practice Name

Physician’s Name

Physician's Name

First

Last

Physician’s Address

Physician's Address

City

State

Zip

Physician’s decision on patient’s participation in an exercise program.

I Approve without Restrictions

I Approve with Restrictions

I DO NOT APPROVE!

If I DO NOT Approve, I understand that my patient will not be accepted into the program.

If APPROVED with restrictions, provide restrictions below:

Physician’s Signature