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) Reset signature Signature locked. Reset to sign again 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) Reset signature Signature locked. Reset to sign again Please sign with mouse, stylus or finger.CAPTCHA Δ
