Bayhealth Physician'S Statement And Medical Clearance Form

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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

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