Physician Release – SlenderSense

Date:*

First Name:*

Last Name:*

Email:*

Phone:*

Address:*

City:*

State/Province/Region:*

Zip/Postal Code:*

I hereby authorize my physician to complete and forward this form to Slender Sense and supply the information requested herein.*

Please sign with mouse, stylus or finger

-- THIS SECTION TO BE COMPLETED BY PHYSICIAN --

Dr. First Name:*

Dr. Last Name:*

Address:*

City:*

State/Province/Region:*

Zip/Postal Code:*

I last examined this patient on:*

My patient may participate fully in a physical activity program consisting of cardiovascular, strength and flexibility training without restrictions or limitations.*

Yes
Yes, with limitations
No

If "YES with Limitations" please describe limitations and/or restrictions:

If your patient is on any medication which may affect heart rate, blood pressure (elevating or suppressing) or otherwise affect response to exercise please indicate such effects and /or limitations / restrictions:

Please indicate any limitations / restrictions placed on this patient due to any disabilities or communicable diseases:

Physician Signature:*

Please sign with mouse, stylus or finger.

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