Monash Medical Clearance Form printable pdf download

Monash Medical Clearance Form

M o n a s h A q u a t i c a n d R e c r e a t i o n C e n t r e

G l e n W a v e r l e y

P h o n e : 0 3 9 2 6 5 4 8 8 8

F a x: 0 3 9 5 6 2 1 3 2 2

MEDICAL CLEARANCE FORM

Your patient _______________________ has applied to participate in a progressive exercise program with Active

Monash which requires your medical clearance prior to participation. Clearance indicates that this patient has no

contradictions for participation in a gentle group training session.

My patient, __________________________________ is physically able to participate in a gentle exercise program

Please list any restrictions or concerns (including medications).

_________________________________________________________________________________________________

Doctors Details

Name: _________________________________ ____

Phone No: __________________________________________

Email: ___________________________________________________________________________________________

Address: _________________________________________________________________________________________

Suburb: ____________________________________

State: ________________

Post Code: ________________

Signature: ___________________________________

Date: _______________________________________

Kind Regards

Carol Syer

Dry Program Coordinator

carolsy@monash.vic.gov.au

Monash Medical Clearance Form