Date:(Required) MM slash DD slash YYYY First Name:(Required) Last Name:(Required) Email:(Required) Phone:(Required)Address:(Required) City:(Required) State/Province/Region:(Required) Zip/Postal Code:(Required) I hereby authorize my physician to complete and forward this form to Commit To Be Fire Fit and supply the information requested herein.(Required)Please sign with mouse, stylus or finger-- THIS SECTION TO BE COMPLETED BY PHYSICIAN --Dr. First Name:(Required) Dr. Last Name:(Required) Address:(Required) City:(Required) State/Province/Region:(Required) Zip/Postal Code:(Required) I last examined this patient on:(Required) MM slash DD slash YYYY My patient may participate fully in a physical activity program consisting of cardiovascular, strength and flexibility training without restrictions or limitations.(Required) 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:(Required)Please sign with mouse, stylus or finger.CAPTCHA
