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Medical Clearance and Physician’s Consent Form
To: Kate Morefield personal trainer and fitness boot camp instructor at PeakEnergy
Fitness Corp
My patient, ____________________________, has advised me that he or she intends
to participate in a fitness program that includes various types of resistance and
cardiovascular training.
Please be advised that my patient should be subject to the following restrictions in his or
her exercise program:
In addition, under no circumstances should my patient do the following:
I have discussed these restrictions and limitations with my patient and, with these
specific restrictions, my patient has my permission to participate in a fitness program
under your guidance.
Truly yours,
__________________________________ Date:_________________________
(Sign name here)
__________________________________ Phone number: _________________
(Print name here)
PeakEnergy Fitness Corp.