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  Fitness Classes or Personal Training Sessions with Susanna Patterson of Y.E.S. Your Exercise Specialist.
I understand that my patient will be participating in activities that may include cardiovascular training as well as strength training, stretching and other forms of exercise. I believe this 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.

__________________________________________________________________

Physician’s or Heath Care provider’s Signature                                        Date

__________________________________________________________________

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

Address______________________________________________________

Phone________________________________________________________

Please add any notes you may have for me here.