SOUTHWIND HEALTH & WELLNESS CENTER



SOUTHWIND HEALTH & WELLNESS CENTER

2309 Sparger Road Durham, NC 27705 (919) 382-0082 Fax: (919) 383-9112

MEDICAL CLEARANCE FORM

Dear Dr.____________________________:

Your patient, _________________________, wishes to exercise at Southwind Health and Wellness Center. Southwind offers fitness evaluations, individualized exercise guidelines, personal fitness training, structured exercise classes, and education classes on nutrition, exercise guidelines, weight training safety, and back care. We utilize various modes of exercise including an indoor walking track, water classes, stationary bikes, treadmills, stairclimbers, free weights, resistance machines, low intensity aerobic classes, stretching and abdominal classes.

Please indicate any restrictions or recommendations that may be appropriate for your patient and return this form in its entirety at your earliest convenience.

____________________________ has my approval to exercise at Southwind Health & Wellness Center with the restrictions or recommendations listed above.

Signature: _______________________________

Date: _____________________

Thank you for taking the time to complete this brief medical clearance for your patient so that he/she can participate in a safe and effective exercise program.

Sincerely,

Southwind Health & Wellness Center

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