Physician’s Clearance Form

On the Physical Activity Readiness Questionnaire you just completed, you either indicated that you were at least 70 years old or you identified that you have one or more medical risk factors, which may impair your ability to exercise safely. Therefore, you must have a physician complete and return this medical clearance form before you can begin/continue participating in personal training with Kroger Enterprises, LLC dba Sozo Health and Fitness. We recognize that you are eager to participate in a fitness program, and we sincerely regret any inconvenience that this may cause you. However, please keep in mind that we want your exercise experience with Kroger Enterprises, LLC dba Sozo Health and Fitness to be as safe as possible. For this reason, we have implemented this policy of requiring a physician’s clearance that follows the current standards of the American College of Sports Medicine.

TO BE COMPLETED BY PROGRAM'S PARTICIPANT

All information will be kept confidential.

I, hereby, give my physician permission to release any pertinent medical information from any medical records to Kroger Enterprises, LLC dba Sozo Health and Fitness.

I understand that a facsimile, electronic, pdf or DocuSigned signature will have the same force and effect as an original.

Patient's Signature *

Date *

TO BE COMPLETED BY THE PHYSICIAN

Please check one of the following three statements:

I concur with my patient’s participation with no restrictions.

I concur with my patient’s participation in an exercise program if he/she restricts the following activities:

I do not concur with my patient’s participation in an exercise program due to the following reasons:

I understand that a facsimile, electronic, pdf or DocuSigned signature will have the same force and effect as an original.

Physician's Signature *

Phone Number *

Print Name *

Date *

Physician’s Clearance Form

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