Medical Release Form

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Division of Student Affairs
Department of Recreational Sports (0358)
142 McComas Hall, Blacksburg, Virginia 24061
540/231-6856 Fax: 540/231-6273
VT Fitness Program - Medical Release Form
Date: _________________
Personal Trainer Name:__________________________
To Physician:
Your patient _____________________________________wishes to start a personalized
training program through the Virginia Tech Personal Training Program. The activities involve
the following:
Type of Activity:
Time/Duration/Intensity:
Cardiovascular:
_____________________________________________
Resistance Training: _____________________________________________
Flexibility:
_____________________________________________
Other:
_____________________________________________
Additional Notes from Trainer:
____________________________________________________________________________
Physician’ Recommendations:
Please identify any recommendations or restrictions that are appropriate for your patient in this
exercise program:
____________________________________________________________________________
____________________________________________________________________________
Please list any medications that your client is currently taking which would impact exercise
training:
____________________________________________________________________________
____________________________________ has my approval to begin an exercise program
with the recommendations or restrictions stated above.
Physician’s Signature____________________
Date__________________________
Print Name: ____________________________
Phone________________________
Thank you for taking the time to fill this out. Please fax to:
Department of Recreational Sports Fitness
Phone: (540) 231-1658
Fax: (540) 231-6273
fitness@vt.edu
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