Doctor’s Consent Form

Most of you will not need a Doctors Consent.  If you answer Yes to any of the questions on the Par-Q and YOU then  you will need to have this form filled in by your doctor. Y.E.S reserves the right to require this form for any other reason.

Date_________________

_______________________________________________________
Patient’s Name

_______________________________________________________
Patient’s Address

____________________________________Phone______________
city    state      zip

I consent to the above named patient’s participation in a Fitness Class held at Y.E.S. Your Exercise Specialist, 301 Commerce Dr. Maumelle, AR 72113.
I understand that my patient will be attending classes that will include cardiovascular training as well as strength training, stretching and other forms of exercise. I believe this class to be safe for my patient. These programs can help build strength, stamina and flexibility.

For more information you may visit www.yourexercisespecialist.com or you may contact Susanna Patterson at 501-944-6955.

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Physician’s or Heath Care provider’s Signature                                                             Date

___________________________________________________________________

Physician’s or Health Care Provider’s Name  (please print legibly)                           Date

Address_____________________________________________________________

Phone________________________________________________________