Medical Clearance for Health Coaching & Fitness Participation (Renew every 12 months)

Medical Clearance for Health Coaching & Fitness Participation (Renew every 12 months)

*Requires Both Client/Patient + Provider Signature
Client/Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Client/Patient Request & Acknowledgement
I am requesting medical clearance to participate in a health coaching and fitness program provided by DRXIVEN LLC, which may include:
- Resistance training and cardiovascular exercise
- Nutrition and lifestyle coaching
- Habit and behavior modification
- General wellness and performance education
I understand:
- These services are non-medical in nature
- They do not replace medical care or supervision
- I am responsible for communicating any changes in my health status
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Provider Section
Provider Name

First NameLast Name
Clinic Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Medical Clearance (Select One)
If Cleared WITH RESTRICTIONS, please provide the following:
Cardiovascular / Vital Sign Parameter
Musculoskeletal / Injury Considerations
Nutrition / Metabolic Considerations
Relevant Medical Conditions
Medications Impacting Exercise Tolerance or Safety
Additional Clinical Recommendations
Provider Attestation
Provider Signature
Provider Name

First NameLast Name
NPI Number
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Program Scope & Liability Notice
DRXIVEN LLC provides health coaching, fitness programming, and nutrition and lifestyle education.

DRXIVEN LLC does NOT diagnose medical conditions, prescribe medications, or replace licensed medical care.

Clients are advised to stop activity and seek medical care if symptoms arise and maintain routine follow-up with their healthcare provider.
DRXIVEN LLC - PROGRAM & PROVIDER INFORMATION
Jacob Alvarado, PharmD, BCACP
Precision Nutrition Level 2 Master Health Coach
ACE Certified Personal Trainer & Health Coach
Owner, DRXIVEN LLC
Email: drxiven@gmail.com
Phone: (915) 277-7724
Should be Empty:

Medical Clearance for Health Coaching & Fitness Participation (Renew every 12 months)

Client/Patient Information

Client/Patient Request & Acknowledgement

Provider Section

If Cleared WITH RESTRICTIONS, please provide the following:

Program Scope & Liability Notice

DRXIVEN LLC - PROGRAM & PROVIDER INFORMATION