Date:* MM slash DD slash YYYY First Name:* Last Name:* Email:* Phone:*Address:* City:* State/Province/Region:* Zip/Postal Code:* I hereby authorize my physician to complete and forward this form to Todd Elliott (fitness trainer) and supply the information requested herein.* Reset signature Signature locked. Reset to sign again Please sign with mouse, stylus or finger-- THIS SECTION TO BE COMPLETED BY PHYSICIAN --Dr. First Name:* Dr. Last Name:* Address:* City:* State/Province/Region:* Zip/Postal Code:* I last examined this patient on:* MM slash DD slash YYYY My patient may participate fully in a physical activity program consisting of cardiovascular, strength and flexibility training without restrictions or limitations.* Yes Yes, with limitations No If "YES with Limitations" please describe limitations and/or restrictions:If your patient is on any medication which may affect heart rate, blood pressure (elevating or suppressing) or otherwise affect response to exercise please indicate such effects and /or limitations / restrictions:Please indicate any limitations / restrictions placed on this patient due to any disabilities or communicable diseases:Physician Signature:* Reset signature Signature locked. Reset to sign again Please sign with mouse, stylus or finger.CAPTCHA Δ
