Physician Medical Release Form

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TO BE COMPLETED BY YOUR PRIMARY CARE PROVIDER









PHYSICIAN’S RECOMMENDATION
















PHYSICIAN’S RECOMMENDATION

If your patient is taking medications that will affect their heart rate response to exercise, please indicate the manner of the effect (raises, lowers or has no effect on heart rate response during exercise:











PHYSICIAN COMPLETES


has my approval to begin the Rock Steady Boxing exercise program with the recommendations or restrictions stated above.