|
Return to the [name of Coordinator]:with your patient,or by mail to:[sponsoring agency]
Fitness Program, TARGETING FITNESS
[location]
or by fax to: [fax]
Patient name __________________________________________Phone___________________
has medical approval to participate in the physical fitness component of the USACHPPM "Targeting Health" Worksite Wellness Program. I understand that the program includes mild to moderate intensity exercise, and is conducted in unsupervised groups or individually. I also understand that participation is voluntary, allowing the participant to stop and rest at any time he or she desires.
The following restrictions apply (if none, so state):
Physician's Name____________________________________________ Physician's Signature_________________________________________ Office telephone number ____________________________ Date___________________
Previous | Next
US Army Center for Health Promotion and Preventive Medicine.
|
