Bayhealth Physician'S Statement And Medical Clearance Form printable pdf download

Lifestyles Fitness Center

Kent General Hospital

1255 S. State Street, Suite 10

Dover, De 19901

Physician’s Statement and Medical Clearance Form

At Bayhealth Lifestyles Fitness Center, your safety is our primary concern. For that reason, we comply with the

health and fitness standards of the American College of Sports Medicine and the International Health, Racquet

and Sportsclub Association.

On the Health History Questionnaire you just completed, you identified that you have one or more coronary

and/or medical risk factors which may impair your ability to exercise safely. For this reason, you need to have a

physician complete and return this medical clearance form before you can begin exercising at Bayhealth

Lifestyles Fitness Center.

We recognize that you are eager to start your fitness program, and sincerely regret any inconvenience that this

may cause you. However, please keep in mind that we want your exercise experience at Bayhealth Lifestyles

Fitness Center to be as safe as possible.

In order to expedite this process, we will gladly fax this form directly to the physician of your choice. If the

doctor is aware of your medical history, he/she may be able to complete this form and fax it right back to us.

I hereby give my physician permission to release any pertinent medical information from any medical

records to the staff at Bayhealth Lifestyles Fitness Center. All information will be kept confidential.

Clientele’s Name_______________________________ Date of Birth________________________________

Physician’s Name_________________________ Fax #_________________Phone#_____________________

For Physician Use Only

Please check one of the following statements:

⁭

I concur with my patient’s participation with no restrictions.

⁭

I concur with my patient’s participation in an exercise program if he/she restricts activities to:

__________________________________________________________________________

⁭

I do not concur with my patient’s participation in an exercise program

(if checked, the individual will not be allowed to join Bayhealth Lifestyles Fitness Center)

Reason: ___________________________________________________________________

Physician’s name (print) _______________________

Sign_______________________________

Date:_____________________

Please return fax to: Lifestyles Fitness Center /Kent FAX(302)

, PHONE(302)

734-3126

-734-4730

Bayhealth Physician'S Statement And Medical Clearance Form