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Physician's Approval

 © 2006

WeBeFit Personal Trainers believe your safety is our primary concern. The Medical History form you filled out identified one or more medical risk factors which may impair your ability to exercise safely. For this reason, you need to have a physician complete and return this Physician's Approval form before you can begin exercising with a WeBeFit Trainer.
I hereby give my physician permission to release any pertinent medical information from any medical records to the staff at WeBeFit. All information will be kept confidential. This form will be completed at no cost to WeBeFit or WeBeFit Personal Trainers.


    PARTICIPANT Name (Print)

    PARTICIPANT Signature

    PARTICIPANT Phone #
Personal Trainer Name (Print)
 Personal Trainer # (Voice & Fax)
Today's Date

YES - The above PARTICIPANT has been examined by me and has my approval to participate in a progressive exercise program. I understand the physical and physiological stressors of the program and see no reason why the above named person should not participate. Any special recommendations and/or contraindications are listed below.


Physician Name (Please Print)

Physician Signature (M.D.)

Today's Date
Physician Address (Street)
 Physician Address (City/State/Zip)
Physician VOICE Number
Physician FAX Number
Activity
Intensity Allowed
Cardiovascular
Resistance Training
Flexibility
Other
Physician's Recommendations/Contraindications:
IMPORTANT! If you do not believe the participant should engage in a progressive exercise program, you must check the NO box below.

NO - The above PARTICIPANT has been examined by me and DOES NOT have my approval to participate in a progressive exercise program.