Medical Release Form Page 2

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Tel:

+44 (0)20 7341 5811

1 Harrington Gardens, London, SW7 4JJ

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Could y ou p lease i ndicate a ny r ecommendations o r r estrictions t hat w ould b e a ppropriate t o y our p atient i n t his

exercise p rogramme?

Thank y ou f or y our t ime.

Sincerely,

______________________________________________________________________________________________

Address/Number/Email

______________________________________________________________________________________________

_____________________________________________________________________________________________

Doctor

My

patient,

has m y a pproval t o

start a s upervised e xercise p rogramme, w ith t he r ecommendations a nd r estrictions s tated a bove.

Signature:

Print N ame:

Date:

Address:

Telephone:

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Parent category: Legal